Depression Case Study: John Doe

Introduction Abhijeet Gupta, a 35-year-old male, presents with

symptoms of major depressive disorder (MDD). This case study
outlines his clinical presentation, diagnostic evaluation, treatment
plan, and progress.
Patient Profile
 Age: 35
 Gender: Male
 Occupation: Software Engineer
 Medical History: Hypertension, managed with medication.
 Family History: Mother had a history of depression.
Clinical Presentation Abhijeet reported a 6-month history of
persistent sadness, lack of interest in activities, fatigue, and difficulty
concentrating. He also experienced insomnia and weight loss.
Diagnostic Evaluation
 Mental Status Examination: Depressed mood, anhedonia, low
energy.
 PHQ-9 Score: 18 (Moderately severe depression)
 Laboratory Tests: Thyroid function tests normal.
 Imaging Studies: None performed.
Diagnosis
 DSM-5 Criteria for Major Depressive Disorder: John met criteria
with symptoms persisting for more than 2 weeks, including
depressed mood, anhedonia, and other associated symptoms.
Treatment Plan
 Medications: Sertraline 50 mg daily.
  Psychotherapy: Cognitive Behavioural Therapy (CBT) weekly.
 Lifestyle Modifications: Encouraged regular exercise, healthy
diet, and sleep hygiene.
 Other Interventions: None at this stage.
Progress and Follow-Up
 Short-term Outcomes: After 4 weeks, John's PHQ-9 score
decreased to 12.
 Long-term Outcomes: At 3 months, PHQ-9 score further
decreased to 6, indicating significant improvement.
 Patient Adherence: John adhered well to medication and
therapy sessions.
 Side Effects: Mild nausea initially, managed with dose
adjustment.
Discussion John's case highlights the importance of a comprehensive
treatment approach combining pharmacotherapy and
psychotherapy. Early intervention and adherence played a key role in
his recovery.
Conclusion Abhijeet’s significant improvement underscores the
efficacy of combined treatment modalities in managing MDD.
Ongoing follow-up is essential to maintain progress and prevent
relapse.