King’s College London

Written Case Presentation with Suggested Care Plan,

Clinical Vignette 1

Module: Challenged in Treating Affective Disorders

Module Code: 7PADGHA – 22/23

Student Number: k21203339

Word Count: 2420

Written Case Presentation with Suggested Care Plan, Clinical Vignette 1 - Anne

Based on the information provided, Anne appears to meet the diagnostic criteria for Major
Depressive Disorder (MDD), with recurrent episodes, according to the DSM-5 guidelines.
For the past 2 months (>2 weeks), Anne has had low mood accompanied with tearfulness,
decreased appetite, fatigued, diminished ability to concentrate and poor sleep.
These symptoms have been severe enough for her to stop working which may indicate the
persistence of the symptoms (Criteria B). However, important to verify how often these
symptoms appear, their severity, and course of illness.

To assess Anna's suspected moderate to severe depressive episode, I would conduct a semi-
structured interview using the Hamilton Rating Scale for Depression (HAM-D). The HAM-D is
a comprehensive tool that evaluates symptoms of MDD from multiple dimensions, including
exploring her anxiety and the effect of her current symptoms on daily functioning.
Additionally, I would gather a detailed history of her symptoms and previous treatments,
assess for any comorbid conditions such as anxiety, and obtain information about her
current lifestyle and past history.

Anne has a history of recurring episodes of prolonged low mood lasting for no less than a
month over the course of the last decade, consisting of feelings of worthlessness and
increased anxiety during routine tasks. Anne has not harmed herself or attempted suicide.
However, it is imperative to corroborate the presence of suicidal ideations, potential
comorbid anxiety, relevant familial history, and any pertinent events or triggers that may
have precipitated these episodes, such as seasonal affective disorder (SAD), head injury or
hormonal fluctuations.

While the current presentation suggests a depressive episode, it is crucial to consider the
possibility of Bipolar Disorder II (BD2) as patients are often diagnosed with unipolar
depression before being diagnosed with BD (Patella et al., 2019). Hypomanic episodes can
have positive effects such as increased energy, creativity, and sociability, which some
patients may enjoy (Greenwood 2017). This makes it difficult to distinguish hypomania as a
mood disturbance, as not all hypomanic episodes are negative.
Written Case Presentation with Suggested Care Plan, Clinical Vignette 1 - Anne

Anne may struggle to differentiate between hypomania and a normal state, especially when
in a depressive episode, and may not remember past hypomanic episodes (APA & DSM-IV).
Anne is 40 years old, which is within the peak age of onset for BD (20-40 years old) (Prabhkar
et al., 2010) Women with BD are more likely to be misdiagnosed with MDD and treated with
ineffective antidepressants, leading to prolonged suffering (Suppes et al., 2005). Therefore,
any history of periods of abnormally elevated mood should be considered to exclude BD.

Given Anne's reported increase in alcohol intake to manage her low mood, it is necessary to
assess her drinking habits to determine whether she may have a substance-induced
depressive disorder and whether her low mood triggered her alcohol intake or vice versa
(Harper & Matsumoto 2020).
Depressive symptoms often co-occur with alcohol use disorder (AUD), leading to more
severe symptoms and worse prognosis for individuals (McHugh et al., 2019).
Evaluating Anne's drinking patterns is crucial to identify if she is experiencing a substance-
induced depressive disorder and exclude the possibility of AUD.

Since Anne consumes more than the recommended national guidelines of >14 units per
week, approximately 35.6 units per week according to the National Health Service (2021)
guidelines. Effective management of her symptoms and improvement of her prognosis will
depend on comprehending the underlying cause of her depression and addressing her
alcohol consumption.

In case Anne is diagnosed with AUD, I would suggest considering bupropion as a treatment
option, given its proven effectiveness in treating MDD and SAD, without interacting with
alcohol (Kenna et al., 2012) To assess the extent of her alcohol dependence, the Severity of
Alcohol Dependence Questionnaire (SADQ) would be used before initiating any
pharmacological treatment for major depressive disorder (MDD).

In addition, I would investigate any patterns surrounding the timing of Anne's depressive
episodes over the past decade and rule out seasonal affective disorder (SAD). Although SAD
typically presents an increase in appetite, and Anne has poor appetite, it is still possible that
Anne may have SAD as she experiences these episodes for a few months every year in the
Written Case Presentation with Suggested Care Plan, Clinical Vignette 1 - Anne

past decade and presents symptoms such as feeling sad, tearful, difficulty concentrating, and
lack of energy. As Melrose (2015) reported, the prevalence of SAD is four times higher in
women.

To rule out underlying conditions that may contribute to depression, such as hypothyroidism
or vitamin deficiencies, it is recommended to conduct blood tests including evaluation of
vitamin D, thyroid function, and hormones (American Association for Clinical Chemistry,
2019).

Worldwide, stress and burnout continue to be a problem among teachers, leading to several
psychological conditions. Anne is a part time teacher, and it is documented that
psychological conditions among teachers are highly prevalent. The incidence of depressive
symptoms in this population can range from 4%-77%. As Anne reported, she currently
stopped working as a part time teacher due to her symptomatology and it is worth
addressing weather her job may play as a trigger for her low mood due to stress, burnout,
anxiety, income etc. (Agyapong et al., 2022)

Perimenopause may increase the risk of Major Depressive Disorder (MDD) in women due to
hormonal shifts, which can make them more vulnerable to depression (Bromberger et al.,
2011). Anne, a 40-year-old woman, may also experience this vulnerability, but her past low
mood episodes are unlikely to be related to perimenopause. Nevertheless, given her age, it
is important to consider the possibility of premenopausal symptoms. If confirmed, a
combination of hormone replacement therapy (HRT), pharmacological, and psychological
interventions may be recommended.

According to Whisman et al. (2006), the contribution of family members to the development
of Major Depressive Disorder (MDD) cannot be underestimated. Specifically, relationship
discord among married wives has been found to be associated with elevated levels of
impairment and distress. Joiner and Katz (1999) further support this notion by
demonstrating that depressive symptoms and mood can be "contagious" within families.
Consequently, when a parent suffers from depression, the impact on the entire family,
including children, can be significant.
Written Case Presentation with Suggested Care Plan, Clinical Vignette 1 - Anne

In accordance with NICE guidelines, a multimodal approach involving SSRI's (Selective

Serotonin Reuptake Inhibitors) and psychotherapy is recommended for the management of
moderate to severe depression. Given Anne's clinical presentation, I would suggest the
initiation of Citalopram. Citalopram may be more effective in reducing depression symptoms
in women compared to men (Rudolph et al., 2014; Kornstein et al., 2000). Recent research
has suggested that Citalopram may help in reducing alcohol craving in individuals with
alcohol use disorder (Zorick et al., 2019). Citalopram may be an effective treatment option
for women with seasonal affective disorder (Partonen et al., 2011; Lam et al., 2014), as it can
reduce symptoms of depression and improve overall quality of life.

Considering Anne's report of poor sleep, fatigue, and lack of energy, which are common side
effects of Citalopram, it would be beneficial to discuss the optimal time for taking her
dosage. Vande et al. (2007) suggest that an evening dose of Citalopram may alleviate sleep
disturbances, while a morning dose may improve mood and energy levels during the day.
Additionally, as Anne may have a comorbid anxiety disorder, Citalopram has been found to
effectively reduce anxiety symptoms in patients with comorbid anxiety (Papakostas, G.I.,
2008; Schweizer et al., 2016).

Based on the Maudsley Prescribing Guidelines (2018), my recommendation for Anne would
be to start with a daily dose of 20 mg of Citalopram for 3-4 weeks. It is essential to monitor
her response closely during this period, and there should be at least a minor improvement
by week 3. If there is no improvement, the dose can be gradually increased to 40 mg daily in
week six. According to the STARD-D trials, 40mg of Citalopram is an effective dose that will
be most likely to achieve remission. (John Rush et al., 2006) [table 1]

Considering Anne's history of recurring low mood episodes, I recommend a minimum of six
months of Citalopram therapy after remission of the acute episode, with the decision to
continue or discontinue medication based on Anne's response and risk of relapse (Anderson
et al., 2008). In addition, continuing taking Citalopram as a maintenance treatment for at
least two years (Dekker et al., 2000). To insure the most effective maintenance treatment for
Anne, I recommend an initial follow up session every two weeks for the first 3 months to
Written Case Presentation with Suggested Care Plan, Clinical Vignette 1 - Anne

assess adherence, tolerability, and side effects. This will allow for any necessary adjustments
to be made to her treatment plan, potentially altering the dosage during remission
maintenance.

Alternatively, switching to another medication would be considered if there is no change

after week 4 from increasing dosage. However, given Anne's history of persistent depressive
episodes, switching medication, or augmenting another SSRI is unlikely to be beneficial (Fava
et al., 2006). Instead, Mirtazapine, a tetracyclic antidepressant with a noradrenergic
mechanism of action, could be a suitable alternative for Anne if she does not respond to
Citalopram. According to John Rush et al. (2006), the efficacy of Mirtazapine in refractory
depression was found to be 12.3%. This is based on the results of the combining medications
to enhance depression outcomes (CO-MED). Mirtazapine is associated with increased
appetite which may be used for Anne’s as she currently reports poor appetite.
I suggest switching Anne's medication from Citalopram to Mirtazapine using a cross-tapering
protocol, which is described in detail in Table 2 (Taylor et al., 2019)

Table 1 – Citalopram (increasing dosage if necessary)

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6

20 mg/day 20 mg/day 20 mg/day 30 mg/day 30 mg/day 40 mg/day

Table 2 – cross tapering plan

Swtich Pre- switch Week 1 Week 2 Week 3 Week 4
From: 40 mg/day 20mg/day 10mg/day 5mg/day Nil
Citalopram
To: N/A 15mg/day 30mg/day 30mg/day 45 mg/day
Mirtazapine (if required)
Written Case Presentation with Suggested Care Plan, Clinical Vignette 1 - Anne

CBT is a psychotherapeutic intervention that aims to help individuals modify negative

thought patterns and behaviours that contribute to their depression. It can teach Anne skills
to identify and challenge negative thoughts, reframe beliefs, and modify unhelpful
behaviours. Studies have consistently demonstrated the effectiveness of CBT in treating
depression (Hofmann & Smits, 2008; Butler et al., 2006) Moreover, as Anne’s depressive
symptoms significantly impacted her ability to function at work which in turn can worsen
symptoms, CBT by developing coping strategies and improving overall quality of life, Anne
may be better able to return to work and maintain productivity. (Glozier, et al., 2010)
Another study found that CBT among teachers may be effective for depression and anxiety.
(Hagan et al., 2016) Also, Research has demonstrated the effectiveness of CBT in preventing
relapse for individuals dealing with depression and alcohol abuse (Magill et al., 2019).

Finally, due to Anne's decade-long history of depression is possible that her relationships
with her immediate family might have been impacted, potentially affecting her support
network. As such, I recommend that once Anne achieves remission, she should consider a
family-based CBT intervention. This approach has been found effective in preventing the
onset of depressive episodes, reducing relapse, and mitigating risks for offspring of parents
who have experienced depression. (Compass et al., 2011, Keitner & Miller 1990)

To conclude, a combination treatment plan of Citalopram and CBT is recommended for

Anne. Once Anne is remitted, I propose family intervention therapy, such as Family CBT.
Written Case Presentation with Suggested Care Plan, Clinical Vignette 1 - Anne

Dear Anne,

Upon receiving your referral letter, I am writing to discuss your treatment plan. I invite you
for a chat to discuss any further information not yet covered. I understand that you have
experienced depressive episodes before, and based on the symptoms you have reported, I
am hopeful that the proposed treatment plan will be beneficial for you.

I recommend Citalopram, an antidepressant medication belonging to the selective serotonin

reuptake inhibitor (SSRI) class which can help alleviate your low mood, improve your sleep,
and increase your energy levels. Side effects of Citalopram may result in nausea, dry mouth,
sweating, and drowsiness. However, these side effects usually subside as your body adjusts
to the medication. Please do not worry as we will monitor your progress closely and address
any concerns you may have along the way.

To start, I recommend taking Citalopram after breakfast, as this timing may help you with
your symptoms of tiredness and poor sleep. Citalopram may be more effective for certain
individuals when taken at night. We can adjust the medication timing to find the best time
for you, based on your reported symptoms.

I would like to emphasize that alcohol acts as a depressant and can worsen your depressive
symptoms. When combined with Citalopram, alcohol can cause sedative effects, potentially
interfering with the medication's effectiveness. If you experience symptoms such as tremors,
sweating, confusion, or fever while discontinuing alcohol consumption, please contact us for
support in managing withdrawal symptoms.

In addition to the medication, I recommend a course of 16 sessions of Cognitive Behavioural

Therapy (CBT) as part of your treatment plan for the next four months. The therapist will
support you in managing your low mood, possible anxiety, and in reducing your alcohol
intake. CBT can help you identify negative thought patterns, develop effective problem-
solving skills to better cope with life stressors, as well as provide tools for managing
emotions and promoting resilience. Hopefully through these efforts, the intensity and
Written Case Presentation with Suggested Care Plan, Clinical Vignette 1 - Anne

duration of your depressive episodes will be diminished, allowing you to experience a

greater sense of well-being.
I'm not currently aware of any confirmed premenopausal symptoms in your case. However,
if you experience them, Hormone Replacement Therapy (HRT) can be considered alongside
your citalopram and CBT treatment. This combination has been shown to be helpful in such
situations.
As a precaution, I have included a "Plan B” if citalopram is not sufficient in relieving your
symptoms. With your consent, I would recommend switching to Mirtazapine. Mirtazapine
has been proven effective in treating depression when SSRIs, like citalopram, do not work.
Once you are remitted, I advise to start family CBT which can be therapeutic process for you
and your family.

I understand that this journey may feel overwhelming, but I'm glad you reached out for help.
You're not alone, and we're here to support you. It may seem impossible now, but the
combination of Citalopram and CBT will gradually help you regain your motivation and well-
being. Our team will monitor your progress and provide assistance throughout. Remember,
it's possible to feel like yourself again, and we'll do our best to help you achieve a full and
speedy recovery.

Yours sincerely,
K21203339
 Written Case Presentation with Suggested Care Plan, Clinical Vignette 1 - Anne

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