Video Case Presentation: A 32-Year-Old Male with Depression and Anxiety
Chief Complaint: The patient presents with complaints of depressed mood, decreased energy, difficulty sleeping, and anxiety symptoms.
History of Present Illness: The patient reports that his symptoms started around six months ago when he lost his job due to the COVID-19 pandemic. He has been struggling with feelings of hopelessness, worthlessness, and guilt. The patient also reports increased anxiety symptoms, including excessive worry, racing thoughts, and panic attacks. He has been unable to sleep and has lost interest in activities he used to enjoy. The patient denies any suicidal or homicidal thoughts.
Pertinent Past Psychiatric History: The patient has a history of depression and anxiety disorder, for which he was previously prescribed sertraline. He discontinued the medication after a few weeks because he felt that it was not helping him. He reports no history of hospitalizations or suicide attempts.
Substance Use History: The patient denies any history of alcohol or drug abuse.
Medical History: The patient has a history of hypertension, which is well-controlled with lisinopril. He denies any other medical conditions.
Social History: The patient is married and has two children. He is currently unemployed due to the pandemic. He denies any history of legal problems or financial difficulties.
Family History: The patient reports a family history of depression and anxiety disorder in his mother and sister.
Mental Status Exam: The patient appears anxious and restless. He is cooperative and engaged in the interview. His mood is depressed, and affect is constricted. His thought processes are logical and organized. There is no evidence of psychosis or suicidal or homicidal ideation. His cognitive functioning is intact, and he has good insight and judgment.
Diagnosis: The patient meets the diagnostic criteria for major depressive disorder and generalized anxiety disorder.
Differential Diagnoses Ruled Out: Other possible differential diagnoses considered and ruled out include adjustment disorder with depressed mood, post-traumatic stress disorder, and bipolar disorder.
Treatment Plan: The patient was started on a selective serotonin reuptake inhibitor (SSRI) and referred for psychotherapy. Follow-up appointments were scheduled to monitor the patient’s response to treatment and to adjust the treatment plan if necessary. The patient was advised to avoid alcohol and drugs and to engage in regular physical activity and self-care practices.