Patient Profile
Patient: Mr. Sameer Joshi, 35-year-old male
Chief Complaint: Persistent sadness, fatigue, and loss of interest for 6 weeks
History & Examination
- Medical history: No prior psychiatric diagnoses
- Symptoms: Insomnia, poor concentration, passive suicidal ideation
- Mental status exam: Psychomotor retardation; no hallucinations or delusions
Investigations
- PHQ‑9: 21 (severe depression)
- Thyroid profile: Normal
- CBC and Vitamin B12: Normal
Diagnosis
Major Depressive Disorder (single episode, severe, without psychotic features) — based on DSM‑5 criteria and PHQ‑9 scoring.
Management Plan
Pharmacological
- Sertraline 50 mg daily to start; titrate per response and tolerability
- Melatonin at night to support sleep
Psychotherapy
- Cognitive Behavioral Therapy (CBT): Weekly structured sessions
- Supportive counseling and psychoeducation
Safety & Follow‑up
- 2 weeks: Check side effects, mood, and adherence
- Monthly: Reassess PHQ‑9, therapy progress, and functioning
- Crisis plan: Provide hotline and rapid-access contact; review suicidality at each visit
Outcome Goals
- Reduce PHQ‑9 to < 5
- Restore functional capacity at work and home
- Prevent relapse and maintain remission
Long‑Term Considerations
- Continue therapy for 6–12 months after remission
- Monitor adherence, side effects, and relapse warning signs
- Encourage social engagement, sleep hygiene, and physical activity
References
- American Psychological Association — Depression Guideline Case Examples.
- University of Auckland — Writing a Psychiatric Case History (PDF Guide).