Clinical Case 2 of 15 · ~708 words
Clinical Case No. 2. A First Depressive Episode in a Working Adult
Onset and initial consultation
Emma is 36. She works as a librarian in Victoria, lives with her partner and sings in an amateur choir once a week. Over two months, her world gradually contracts. First she stops replying to friends, then misses rehearsals, and eventually notices that even a day off brings no relief. At work, she reads the same paragraph repeatedly. In the morning, she wakes earlier than necessary and lies awake considering her supposed professional inadequacy.
The reason for seeking help is ordinary: for the third time, she forgets to prepare materials for a children's event. Her family physician, who has known her for several years, schedules a separate, longer appointment. Emma calls it exhaustion. Her partner, present for the end of the conversation with Emma's consent, describes changes at home: favourite activities have lost their appeal, and evenings together pass mostly in silence.
On examination, Emma is well groomed and engaged but answers more slowly than usual. Mood is persistently low, pleasure is almost absent, sleep and appetite are disturbed, and energy is limited. Her self-appraisal has become disproportionately harsh. She sometimes thinks it would be easier not to wake up but denies suicidal intent or a plan. The physician asks about previous attempts, available means, alcohol, her ability to seek help and support at home.
Her PHQ-9 score is 17; it will be repeated during treatment alongside assessment of functioning. Emma denies periods of increased energy with reduced need for sleep, unusual spending or disinhibition; there is no relevant family history. There are no psychotic symptoms, stimulant use or a new medication that would explain the changes.
Physical examination reveals no significant abnormalities. Fatigue and appetite changes prompt a complete blood count and thyroid testing: haemoglobin is 132 g/L and TSH 1.8 mIU/L. The history and mental state together are consistent with a first major depressive episode of moderate severity, without psychotic features.
Treatment choice and the first weeks
Emma would prefer to begin with psychological care but fears losing her job. After discussing the options, they choose gradually introduced sertraline and CBT-based interventions. The goals are to restore sleep, concentration, work capacity and enjoyment of familiar activities. [40]
Emma has a regular family physician, support at home and the option of temporarily reducing her workload. She joins the free BounceBack program, working through CBT materials with telephone support from a trained coach. Her physician continues clinical follow-up and risk assessment. [41]
After the first week, Emma calls about nausea. The physician clarifies its severity, medication use and other symptoms; they agree to increase the dose more slowly. Over the following weeks, sertraline reaches 100 mg daily. The next contact is booked in advance.
Behavioural activation begins with short walks and one small task each day. Manageable activity gradually interrupts the cycle of inactivity, guilt and exhaustion. Later, Emma learns to notice the automatic conclusion, "If I've made a mistake, I'm not fit for the job."
At Emma's request, her partner regularly invites her to walk together. When she returns to choir rehearsal, she stays for half the session and a little longer the following week.
Remission, maintenance and completing treatment
By week six, sleep is better, passive thoughts of death have disappeared and PHQ-9 has fallen to 9; concentration and pleasure recover more slowly. After three months, Emma is working full-time again, scores 4 on PHQ-9 and can plan the next month without a sense of inevitable failure.
After remission, treatment continues for approximately nine months, taking recurrence risk and tolerability into account. CANMAT provides for 6 to 12 months of maintenance treatment for many patients and a longer course when relapse risk is higher. [40]
Sexual adverse effects persist longer than nausea and influence the decision about treatment duration. Once her condition is stable, the dose is reduced gradually. Brief dizziness after one reduction is assessed as a possible discontinuation symptom, and the next step is slowed. Follow-up examines anhedonia, early waking and self-blame.
At a later review, Emma is working, singing and has completed her antidepressant course. She recognizes early signs of deterioration and has an agreement to return to her physician.