Major Depressive Disorder: Case Study and Treatment Approaches

Introduction: MDD and the Case of Taylor

The term "Prozac Nation" says a lot. This catchphrase began to describe the state of affairs in the United States as cases of clinical depression surged and medication became the first-line response. According to the National Institute of Mental Health, over fourteen million adults in the U.S. suffer from Major Depressive Disorder. Major Depressive Disorder, or MDD, is the leading cause of disability in people ages 15–44. The average age of onset is 32 (U.S. Department of Health and Human Services, 2011). It is often found co-occurring with other mental disorders, such as anxiety and substance abuse. A case example helps illuminate this often debilitating disorder and how it presents in clinical practice.

Taylor is a 24-year-old single, Jewish female presenting with symptoms of depression. She reports that for the last six months she has struggled with feelings of emptiness, loneliness, chronic sadness, and fatigue. She also states that she has not enjoyed activities she used to engage in recreationally, such as playing the piano and painting. Taylor sleeps fitfully and consequently tends to nod off in her college classes during the day. Lately, she has been drinking more alcohol at night to help her fall asleep and quiet her anxious thoughts, but does not find that it helps consistently. Her appetite is also severely diminished and she has lost 15 pounds without trying. Taylor reports constant negative, nagging thoughts and feels bad about herself in general — she feels worthless. Though she would not actually hurt herself, Taylor reports passive suicidal ideation, wishing she simply would not wake up in the morning, and wanting to do anything to "make the pain stop."

Diagnosis and Background

Taylor had been living with her boyfriend, Ted, for the last two years in his apartment in the city. She would describe their relationship as "on and off," but claims that she loves him. One day, Taylor came home to find herself locked out with her belongings packed, and learned that Ted had decided to end the relationship for unspecified reasons. He refused to discuss it, stating only that he "needs his space" and "wants to move on." Since that day, Taylor began experiencing all of the above-mentioned symptoms. What began as normal sadness and grief over the rejection steadily worsened into the debilitating state of depression she currently experiences. She finds it hard to get out of bed in the mornings and, despite the weight of depression making her sluggish, still attempts to attend her classes.

Though Taylor identifies as Jewish — a minority population in the state where she lives — she is not observant and considers herself very secular. She was raised in a traditional family in which Jewish identity was acknowledged, but as she moved away from home at age 17 to attend college, she left those ideals behind and stopped identifying with her Jewish roots. She later fell in love with Ted, a devout Christian, and though her parents did not approve, she did not see the religious difference as an issue in their relationship. Now, amid all the self-doubt that plagues her, she wonders whether religion was, in fact, an underlying issue for Ted — one of many unanswered questions she carries. She has since moved back in with her parents, where the prevailing attitude is "you are better off without him," which is far from supportive of how she is actually coping with the loss.

Taylor's symptoms qualify for the clinical diagnosis of Major Depressive Disorder according to the DSM-IV-TR. She reports experiencing seven of the nine diagnostic criteria, and because her symptoms have persisted for six months, she has surpassed the diagnosable timeframe for Adjustment Disorder with Depressed Mood (Quick Reference to the Diagnostic Criteria from DSM-IV-TR, 2000). Taking her symptoms and her goal of returning to pre-breakup functioning into account, several psychotherapeutic approaches may prove helpful.

Treatment Options: Medication and CBT

Taylor has never been in treatment before, but she comes in now because she can no longer tolerate the way depression is interfering with her quality of life and feels she needs a supportive figure to help her sort through her issues. She is motivated for change. As her therapist, I would discuss the various treatment approaches from which Taylor might benefit.

To begin, medication treatment can be very helpful in a case like Taylor's, which is not a long-term or chronic depression but appears reactive to a specific loss. Any of the available antidepressant options — such as SSRIs, MAOIs, or SNRIs — would target the biochemical dimension of the depression and may help take the edge off her depressed mood (Martin, 2010). This could in turn allow her to think more clearly about her goals and engage more fully in therapy to develop more effective coping strategies. Research on the combined effectiveness of medication and psychotherapy shows greater symptom reduction in adult depression than psychotherapy alone (Cuijpers, van Straten, Hollon, & Andersson, 2010). Explaining how psychotherapy can address her particular situation would be an important next step.

Cognitive Behavioral Therapy (CBT) has been empirically proven to help people who suffer from Major Depression. It is widely accepted that symptom reduction can be expected after engaging in a course of CBT treatment. The mechanism works by teaching clients that they can influence their mood by changing their thoughts and behaviors (Rupke, Blecke, & Renfrow, 2006). On the cognitive side, several tools can be used effectively during sessions to encourage client motivation and collaboration. These include a "Daily Mood Log," which is used to track negative thoughts and encourage thought restructuring, as well as symptom rating scales that help both patient and therapist gauge progress more objectively (Burns, 1989). Taylor may find CBT particularly helpful in addressing the negative thought patterns affecting her sense of self-worth following the breakup, and in quieting persistent self-doubt.