A 35-year-old woman comes to the office due to insomnia and fatigue over the past month. She has felt increasingly depressed, irritable, and worthless since being let go from her job 5 weeks ago. The week prior to her last menstrual period was particularly difficult, and she stayed in bed most of the day. Over the last month, the patient has lost 3.6 kg (8 lb) and has felt unmotivated and unable to concentrate on looking for new work. Other medical conditions include hypothyroidism and migraine headaches. The patient drinks 1 or 2 glasses of wine a few times a week and smokes marijuana once a month. Medications include levothyroxine and naproxen. Physical examination is normal. TSH level is 0.9 µU/mL. Which of the following is the most likely diagnosis in this patient?

Question

A 35-year-old woman comes to the office due to insomnia and fatigue over the past month.  She has felt increasingly depressed, irritable, and worthless since being let go from her job 5 weeks ago.  The week prior to her last menstrual period was particularly difficult, and she stayed in bed most of the day.  Over the last month, the patient has lost 3.6 kg (8 lb) and has felt unmotivated and unable to concentrate on looking for new work.  Other medical conditions include hypothyroidism and migraine headaches.  The patient drinks 1 or 2 glasses of wine a few times a week and smokes marijuana once a month.  Medications include levothyroxine and naproxen.  Physical examination is normal.  TSH level is 0.9 µU/mL.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec160b_3618_d0b0_9249_97eca0854ddc_MD0001_00 This patient's symptoms (eg, depressed mood, feelings of worthlessness, low energy, insomnia, weight loss, and poor concentration) lasting ≥2 weeks meets the criteria for major depressive disorder (MDD). The presence of MDD criterion symptoms for ≥2 weeks is all that is required for diagnosis, but the median duration of an MDD episode is approximately 6 months. Accurate diagnosis of MDD requires ruling out medical and substance-induced causes. Despite a history of hypothyroidism in this patient, her normal TSH level indicates that her hypothyroidism is adequately controlled with levothyroxine and would not be considered a medical cause of her depression (Choice C). Patients with sufficient depressive symptoms are diagnosed with MDD even if there is a clear psychosocial stressor that precipitated the depression (ie, this patient meets the criteria for MDD and therefore cannot be diagnosed with an adjustment disorder) (Choice A). In patients who do not meet the criteria for MDD, adjustment disorder with depressed mood may be diagnosed if sadness, distress, and functional impairment develop ≤3 months following a psychosocial stressor. (Choice B) This patient has no known history of hypomanic episodes required for a diagnosis of bipolar II disorder. (Choice E) Persistent depressive disorder is diagnosed when depressive symptoms have lasted ≥2 years. It includes both pure dysthymia and chronic major depression. (Choice F) Some women with mood disorders report that their symptoms worsen before their menstrual periods. However, in premenstrual dysphoric disorder, depressive symptoms must remit with the onset of menses and the diagnosis must be confirmed by daily prospective ratings over several cycles. (Choice G) In substance-induced depressive disorder, a substance (eg, drug of abuse, medication, toxin) is judged to be etiologically related to the mood disturbance. The extent of this patient's substance use makes it an unlikely cause of her depressive disorder. Educational objective: Patients with sufficient depressive symptoms are diagnosed with major depressive disorder even if there is a clear psychosocial stressor that precipitated the depression. __________ References: Major depressive disorder in DSM-5: implications for clinical practice and research of changes from DSM-IV. (http://www.ncbi.nlm.nih.gov/pubmed/24272961)

A 35-Year-Old Woman Comes to the Office Due to Insomnia