Question
27-year-old woman comes to the physician because of sadness that started 6 weeks after her 9-month-old daughter was born. Since then, she has not returned to work. Her daughter usually sleeps through the night, but the patient still has difficulty staying asleep. She is easily distracted from normal daily tasks. She used to enjoy cooking, but only orders delivery or take-out now. She says that she always feels too exhausted to do so and does not feel hungry much anyway. The pregnancy of the patient’s child was complicated by gestational diabetes. The child was born at 36-weeks’ gestation and has had no medical issues. The patient has no contact with the child’s father. She is not sexually active. She does not smoke, drink alcohol, or use illicit drugs. She is 157 tall and weighs 47 kg; BMI is 20 kg/m2. Vital signs are within normal limits. She is alert and cooperative but makes little eye contact. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?
| A. |
Adjustment disorder
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| B. |
Depression with peri partum onse
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| C. |
Major depressive disorder
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| D. |
Normal behaviour
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Show Answer
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Correct Answer � C
Explanation
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Major depressive disorder
Adjustment disorder
Adjustment disorder is a response to a psychosocial stressor that may manifest as symptoms of depression or anxiety (which do not meet the full criteria for any other psychiatric diagnosis) that last for up to 3–6 months after resolution of the stressful event. Because this patient has now had symptoms for 7.5 months after her delivery, adjustment disorder can be ruled out.
Depression with peripartum-onset
To meet the DSM-V criteria for depression with peripartum-onset, symptoms must fulfill the criteria for major depressive disorder and onset of symptoms must begin during pregnancy or within 4 weeks of delivery. Although, this patient meets criteria for a major depressive episode, her symptoms started 6 weeks after her delivery.
Additional Information
While still commonly used in clinical practice, postpartum depression is no longer considered a separate diagnosis under the DSM-V.
Major depressive disorder
To meet the criteria for a major depressive disorder, a patient must have 5 or more symptoms of depression (SIGECAPS), one of which must be depressed mood or anhedonia, for at least 2 consecutive weeks. Symptoms must not be attributable to substance use or other medical conditions. Bipolar disorder and psychosis must also be excluded. This patient meets the criteria because she has had 7.5 months of insomnia, anhedonia (used to enjoy cooking), exhaustion, poor concentration, and decreased appetite. She has never had an episode of hypomania or mania and her symptoms are not better explained by a psychotic disorder or substance use. The next best step in management for this patient is starting her on an antidepressant, such as an SSRI, and attempting lifestyle changes, possibly with the help of psychotherapy.
Normal behavior
Normal behavior may include occasional feelings of sadness or tearfulness for < 2 weeks. While this patient has had recent stress which may trigger such feelings, she has had multiple, significant depressive symptoms for 7.5 months, which is no longer considered normal.
