9- Major Depression

Case 9 - Clinical History: (pp. 124-128)

Key Answer: B. Major Depressive Disorder, single episode, moderate

Explanation:
Liona meets the criteria for a Major Depressive Episode (≥2 weeks of depressed/irritable mood, fatigue, sleep disturbance, low appetite, loss of interest, guilt, and suicidal ideation) without any history of manic/hypomanic episodes. Therefore, the appropriate DSM-5 diagnosis is Major Depressive Disorder, single episode, moderate.

Note: DSM-5 code 296.22 is used for this diagnosis (equivalent to ICD-10 code F32.1 in DSM-5-TR).

Which of the following best describes Liona’s DSM-5 diagnosis?

A. Persistent Depressive Disorder, with pure dysthymic syndrome
B. Major Depressive Disorder, single episode, moderate
C. Adjustment Disorder with depressed mood
D. Bipolar II Disorder

Key Answer: C. Frequent arguments with peers and parents

Explanation:
In children and adolescents, depression may manifest as irritability rather than sadness. Liona’s increased arguments and oppositional behavior are examples of mood irritability, fulfilling the mood disturbance criterion in DSM-5.

Note: DSM-5 recognizes irritability as an alternative to depressed mood in diagnosing MDD among youth.

Which of the following symptoms in Liona best represents the irritability subtype of depression common in adolescents?

A. Fatigue and loss of energy
B. Suicidal ideation
C. Frequent arguments with peers and parents
D. Early-morning awakening

Key Answer: C. Periods of euphoria or grandiosity

Explanation:
Euphoria and grandiosity are symptoms of mania or hypomania, not depression. The other listed symptoms (A, B, D) are all part of DSM-5’s major depressive episode criteria.

Note: The absence of manic or hypomanic symptoms is required to confirm 296.22 Major Depressive Disorder, Single Episode, Moderate.

Which of the following is NOT one of the DSM-5 criteria for a major depressive episode?

A. Fatigue or loss of energy
B. Feelings of worthlessness or excessive guilt
C. Periods of euphoria or grandiosity
D. Diminished ability to think or concentrate

Key Answer: C. The transition from a public to a private school environment

Explanation:
Liona experienced significant stress when she transitioned to an upper-middle-class private school, where she felt socially isolated and economically disadvantaged. Such transitions are known environmental stressors that can trigger depression in adolescents.

Which psychosocial stressor most likely contributed to Liona’s depressive episode?

A. Her participation in swimming team activities
B. Her father’s return to Mexico for work
C. The transition from a public to a private school environment
D. Her mother’s stable employment

Key Answer: B. Duration of depressive symptoms

Explanation:
The main distinguishing feature between PDD and MDD is duration. PDD requires symptoms most days for at least 2 years (or 1 year in children/adolescents), while MDD requires a minimum duration of 2 weeks.

Note: Liona’s depressive symptoms intensified only over the past year, which does not meet the duration threshold for PDD — hence, her diagnosis remains 296.22 Major Depressive Disorder, Single Episode, Moderate.

Which of the following features distinguishes Persistent Depressive Disorder (PDD) from Major Depressive Disorder (MDD) in DSM-5?

A. Presence of suicidal ideation
B. Duration of depressive symptoms
C. Severity of fatigue and irritability
D. Family history of depression

Key Answer: B. Scratching her wrist with a razor blade

Explanation:
Liona made a suicidal gesture by superficially scratching her wrist with a razor blade three months before her clinic intake, followed by suicidal thoughts while swimming. These behaviors support the “recurrent thoughts of death” criterion for MDD.

What suicidal behavior did Liona engage in prior to her clinic visit?

A. Attempted overdose with medication
B. Scratching her wrist with a razor blade
C. Writing a suicide note but no self-harm
D. Jumping off a building

Key Answer: B. Her mother’s previous episode of depression

Explanation:
Depression has a strong genetic and familial component. Liona’s mother, maternal aunt, and paternal grandfather each had histories of depression, indicating a heritable vulnerability to mood disorders.

Which family factor most strongly supports a biological predisposition to depression in Liona’s case?

A. Her father’s physical illness
B. Her mother’s previous episode of depression
C. Her parents’ divorce
D. Her gifted academic history

Key Answer: B. Single episode, moderate

Explanation:
Liona has experienced only one major depressive episode with moderate severity, meaning her symptoms cause noticeable impairment but do not meet the threshold for “severe” or “psychotic” features.

Note: Correct DSM-5 code: 296.22 Major Depressive Disorder, Single Episode, Moderate.

Which of the following DSM-5 specifiers is correctly applied to Liona’s diagnosis?

A. Recurrent episode, severe
B. Single episode, moderate
C. Chronic, severe
D. With psychotic features

Key Answer: B. Her symptoms began gradually around age 11 and worsened over time.

Explanation:
The case notes that Liona’s depression began at age 11 and intensified during the year preceding her clinic visit, consistent with a gradual onset typical of major depression in adolescents.

Which of the following statements about the onset of Liona’s depressive symptoms is most accurate?

A. Her symptoms appeared suddenly after her father’s illness.
B. Her symptoms began gradually around age 11 and worsened over time.
C. Her depression started only after changing schools.
D. Her symptoms began following a single traumatic event.

Key Answer: B. Feeling detached from her body or as if in a dream.

Explanation: Depersonalization is a dissociative symptom involving a sense of detachment from one’s body or surroundings. Liona described feeling “like she was in a dream or detached from her body,” matching this definition.

Which of the following best illustrates psychological depersonalization reported by Liona?

A. Thinking she was being watched by others.
B. Feeling detached from her body or as if in a dream.
C. Hearing voices criticizing her.
D. Losing awareness during arguments.

Key Answer: C. The severity and duration of symptoms

Explanation:
Adjustment Disorder involves emotional symptoms in response to a stressor but does not meet full criteria for MDD in terms of number, intensity, or persistence of symptoms. Liona’s symptoms lasted over a year and met full MDD criteria.

Which of the following best differentiates Major Depressive Disorder from an Adjustment Disorder with depressed mood?

A. The presence of family stress
B. The presence of suicidal ideation
C. The severity and duration of symptoms
D. The patient’s age at onset

Key Answer: B. Psychosocial and interpersonal stressors

Explanation:
Her depression was linked to family conflict, peer difficulties, and school transition—all interpersonal and psychosocial stressors, which are common precipitants in adolescent depression.

Liona’s depressive symptoms were most likely intensified by which type of stressor?

A. Physical trauma
B. Psychosocial and interpersonal stressors
C. Neurological disease
D. Substance use

Key Answer: B. Immediately assess suicide risk and establish a safety plan

Explanation:
Any report of suicidal ideation requires immediate safety assessment, exploration of intent and means, and development of a safety plan. Postponing or deferring this assessment would be clinically unsafe.

What is the most appropriate next clinical step after Liona disclosed suicidal thoughts during intake?

A. Continue the interview and assess next week
B. Immediately assess suicide risk and establish a safety plan
C. Ask her mother to monitor her at home without professional follow-up
D. Prescribe medication without further assessment

Key Answer: B. Recurrent exposure to parental conflict and abuse

Explanation:
Repeated exposure to domestic violence, parental inconsistency, and abandonment can lead to internalized guilt and low self-worth—core cognitive features of depression.

Which of the following factors in Liona’s history may contribute to her low self-esteem and feelings of worthlessness?

A. Supportive peer relationships
B. Recurrent exposure to parental conflict and abuse
C. Excellent academic performance
D. Stable family structure

Key Answer: B. Cultural identity and socioeconomic context influence her symptom expression.

Explanation:
DSM-5 emphasizes cultural formulation, recognizing that ethnic background and socioeconomic stress (e.g., minority status in a private school, poverty) affect how depressive symptoms are experienced and communicated.

Which of the following features makes Liona’s case culturally relevant from a DSM-5 perspective?

A. Her diagnosis depends on her being bilingual.
B. Cultural identity and socioeconomic context influence her symptom expression.
C. Culture does not affect the diagnosis of depression.
D. Hispanic children cannot be diagnosed with MDD.

Key Answer: B. She has suicidal ideation but no persistent plan or intent.

Explanation:
“Moderate” depression implies clear functional impairment and suicidal ideation, but not the psychosis, severe self-neglect, or high suicide risk that would warrant a “severe” specifier.

Note: DSM-5 code remains 296.22 Major Depressive Disorder, Single Episode, Moderate.

Which of the following aspects of Liona’s presentation indicates a moderate rather than severe level of depression?

A. She has psychotic symptoms.
B. She has suicidal ideation but no persistent plan or intent.
C. She has stopped all social contact and daily functioning.
D. She requires hospitalization for safety.

Key Answer: B. With anxious distress

Explanation:
Liona shows excessive worry, tension, and fear of doing something wrong, meeting the criteria for the specifier “with anxious distress”, which can accompany MDD.

Which of the following specifiers could also be considered for Liona’s depressive episode based on her presentation?

A. With psychotic features
B. With anxious distress
C. With catatonia
D. With seasonal pattern

Key Answer: C. Ongoing parental discord and inconsistent boundaries at home

Explanation:
Family therapy is indicated when family conflict, poor communication, or inconsistent parenting contribute to the adolescent’s depressive symptoms and relational stress.

Which factor in Liona’s history most strongly indicates the need for family therapy as part of her treatment plan?

A. Her father’s absence
B. Her conflicts with peers
C. Ongoing parental discord and inconsistent boundaries at home
D. Her perfectionism in school

Key Answer: B. Cognitive-behavioral therapy (CBT) focused on mood and coping skills

Explanation:
For moderate adolescent depression, CBT and/or interpersonal therapy (IPT) are first-line treatments. They target negative thought patterns, build coping skills, and address social conflicts.

Which of the following treatment approaches would likely be most beneficial as an initial intervention for Liona?

A. Electroconvulsive therapy (ECT)
B. Cognitive-behavioral therapy (CBT) focused on mood and coping skills
C. Long-term psychodynamic analysis only
D. Antipsychotic medication

Key Answer: B. Improved mood stability, coping with stressors, and restored functioning

Explanation:
Treatment goals for depression focus on symptom reduction, emotional regulation, and improved functioning in school, family, and peer relationships—not the unrealistic goal of never feeling sad again.

Which long-term goal would best reflect successful treatment outcomes for Liona?

A. Elimination of all sadness permanently
B. Improved mood stability, coping with stressors, and restored functioning
C. Dependence on therapist support
D. Complete avoidance of emotional expression

Key Answer: B. A history of manic or hypomanic episodes

Explanation:
DSM-5 states that a past manic or hypomanic episode excludes Major Depressive Disorder and indicates Bipolar Disorder instead. Liona’s history shows no manic symptoms.

Note: DSM-5 Code: 296.22 – Major Depressive Disorder, Single Episode, Moderate

Which of the following would rule out a diagnosis of Major Depressive Disorder in Liona’s case?

A. Presence of fatigue and low energy
B. A history of manic or hypomanic episodes
C. Sleep and appetite disturbance
D. Feelings of worthlessness and guilt

Key Answer: B. Persistent Depressive Disorder (PDD)

Explanation:
When depressive symptoms last for two years or longer without full remission, DSM-5 criteria for PDD are met. Liona’s symptoms have lasted about one year, so PDD is not yet applicable.

Which diagnosis should be considered if Liona’s depressive symptoms persisted for over two years without remission?

A. Adjustment Disorder with depressed mood
B. Persistent Depressive Disorder (PDD)
C. Cyclothymic Disorder
D. Major Depressive Disorder, recurrent

Key Answer: B. GAD centers around chronic worry, while MDD centers around sadness and anhedonia

Explanation:
While there’s overlap (e.g., irritability, fatigue), GAD is characterized by excessive, uncontrollable worry, whereas MDD emphasizes persistent sadness, loss of interest, and hopelessness.

Which of the following best differentiates Major Depressive Disorder from Generalized Anxiety Disorder (GAD)?

A. Both disorders include irritability and fatigue
B. GAD centers around chronic worry, while MDD centers around sadness and anhedonia
C. Only MDD involves sleep disturbance
D. Both disorders are identical in DSM-5

Key Answer: B. Bipolar I Disorder

Explanation: A manic episode automatically establishes a diagnosis of Bipolar I Disorder, even if previous episodes were depressive.
If only hypomanic episodes occurred, the diagnosis would be Bipolar II.

Which diagnosis would be most appropriate if Liona later developed a full manic episode?

A. Major Depressive Disorder, recurrent
B. Bipolar I Disorder
C. Bipolar II Disorder
D. Cyclothymic Disorder

Key Answer: B. Cognitive-Behavioral Therapy (CBT)

Explanation:
CBT is one of the most evidence-based interventions for adolescent depression. It targets negative automatic thoughts, teaches coping skills, and improves mood regulation.

Which type of therapy has the strongest empirical support for adolescent depression like Liona’s?

A. Electroconvulsive therapy (ECT)
B. Cognitive-Behavioral Therapy (CBT)
C. Prolonged exposure therapy
D. Dialectical Behavior Therapy (DBT)

Key Answer: C. Selective Serotonin Reuptake Inhibitors (SSRIs)

Explanation:
SSRIs (e.g., fluoxetine, escitalopram) are first-line antidepressants for adolescents, per FDA and AACAP guidelines. They are used when psychotherapy alone is insufficient or depression is moderate to severe.

If Liona’s depressive symptoms do not respond adequately to psychotherapy alone, which pharmacological approach is most appropriate to consider next?

A. Benzodiazepines
B. Antipsychotics
C. Selective Serotonin Reuptake Inhibitors (SSRIs)
D. Stimulants

Key Answer: C. Ongoing family conflict and inconsistent parental involvement

Explanation:
Family-based therapy is indicated when family dynamics, conflict, or communication problems maintain or worsen the adolescent’s depression. Liona’s parents’ instability and arguments are key targets for intervention.

Which factor in Liona’s history indicates a need for family-based intervention in addition to individual therapy?

A. Her strong communication skills
B. Her supportive extended family network
C. Ongoing family conflict and inconsistent parental involvement
D. Her good peer relationships

Key Answer: B. More irritability and somatic complaints

Explanation:
Adolescents often display irritability, fatigue, or physical complaints (e.g., headaches) instead of overt sadness. Liona’s irritability and headaches fit this developmental presentation.

From a developmental standpoint, which of the following is most typical of adolescent depression compared to adult depression?

A. Less irritability and more guilt
B. More irritability and somatic complaints
C. Greater cognitive distortions
D. Higher rates of psychotic symptoms

Key Answer: B. Maintaining confidentiality but breaching it if safety is at risk

Explanation:
Clinicians must balance confidentiality with the duty to protect. Suicidal ideation justifies notifying parents or guardians to ensure the adolescent’s safety.

Which ethical consideration is most important when treating an adolescent like Liona who reports suicidal ideation?

A. Absolute confidentiality with no exceptions
B. Maintaining confidentiality but breaching it if safety is at risk
C. Not involving parents under any circumstances
D. Allowing the patient to decide whether to tell her parents

Key Answer: C. Good insight, treatment adherence, and family involvement

Explanation:
Positive treatment outcomes are associated with early intervention, strong family support, insight into symptoms, and consistent participation in therapy.

Note: DSM-5 Code remains 296.22 – Major Depressive Disorder, Single Episode, Moderate.

Which of the following factors would predict a better prognosis for Liona’s depressive disorder?

A. Chronic family conflict and poor social support
B. Early onset and multiple episodes
C. Good insight, treatment adherence, and family involvement
D. Presence of comorbid anxiety and substance use

Answer: A. Symptom onset within 3 months of a stressor

Explanation: Adjustment Disorder arises after a specific identifiable stressor, and symptoms resolve within 6 months after the stressor ends. MDD can occur without an external trigger and lasts longer.
Note: DSM-5 Code 296.22.

Which feature most clearly distinguishes Major Depressive Disorder from Adjustment Disorder with Depressed Mood?

A. Symptom onset within 3 months of a stressor
B. Functional impairment at school or work
C. Sleep and appetite changes
D. Sadness and tearfulness

Answer: A. Intrusive re-experiencing of a traumatic event

Explanation: Recurrent, distressing memories or flashbacks of trauma define PTSD, not MDD. Both share negative mood, but trauma re-experiencing is diagnostic of PTSD.
Note: DSM-5 Code 296.22.

Which of the following best differentiates Major Depressive Disorder from Post-Traumatic Stress Disorder (PTSD)?

A. Intrusive re-experiencing of a traumatic event
B. Depressed mood and loss of interest
C. Sleep disturbance
D. Irritability and guilt

Answer: A. Evaluate onset before age 12 and across settings

Explanation: ADHD requires evidence of persistent symptoms since childhood in multiple contexts. Concentration problems in MDD appear after depressive onset.
Note: DSM-5 Code 296.22.

Liona reports difficulty concentrating, restlessness, and fatigue. Which step helps rule out ADHD as a comorbidity?

A. Evaluate onset before age 12 and across settings
B. Ask about sleep and appetite changes
C. Screen for trauma exposure
D. Administer a personality inventory

Answer: A. In partial remission

Explanation: “Partial remission” applies when symptoms improve but some remain or relapse occurs before full recovery. A “recurrent” specifier requires two distinct episodes separated by at least 2 months of full remission.
Note: DSM-5 Code 296.22.

If Liona’s mood improves for 2 months and then relapses, what is the most accurate DSM-5 specifier?

A. In partial remission
B. With anxious distress
C. Recurrent episode
D. Persistent depressive disorder

Answer: B. CBT plus SSRI plus family involvement

Explanation: The Treatment for Adolescents with Depression Study (TADS) found the combination of CBT + fluoxetine + family participation most effective and safest for moderate-to-severe cases.
Note: DSM-5 Code 296.22.

Which integrated treatment plan has the best empirical support for moderate adolescent depression?

A. Medication alone
B. CBT plus SSRI plus family involvement
C. Psychodynamic therapy alone
D. School counseling only

Answer: B. Maintenance CBT sessions focusing on early-warning signs

Explanation: Continuation and maintenance-phase CBT helps patients recognize triggers and apply coping strategies to prevent recurrence. Relapse rates drop significantly when therapy continues beyond acute recovery.
Note: DSM-5 Code 296.22.

Which intervention targets relapse prevention most directly?

A. Increasing medication dosage only
B. Maintenance CBT sessions focusing on early-warning signs
C. Switching to benzodiazepines
D. Ending therapy after symptom relief

Answer: A. Increasing reward-based engagement to counter inactivity

Explanation: Behavioral activation combats anhedonia by scheduling and reinforcing pleasurable, mastery-oriented activities, gradually improving mood and motivation.
Note: DSM-5 Code 296.22.

Liona’s clinician introduces behavioral activation. What is the primary mechanism of this approach?

A. Increasing reward-based engagement to counter inactivity
B. Exploring unconscious conflicts
C. Challenging cognitive distortions
D. Practicing mindfulness only

Answer: C. Ongoing family stress or parental depression

Explanation: Chronic interpersonal conflict and parental mental illness increase vulnerability to recurrence even after successful treatment.
Note: DSM-5 Code 296.22.

Which psychosocial factor is most predictive of relapse in adolescent depression?

A. Good school performance
B. Strong family cohesion
C. Ongoing family stress or parental depression
D. High treatment adherence

Answer: C. Considering how cultural norms affect symptom expression and help-seeking

Explanation: DSM-5 encourages clinicians to apply the Cultural Formulation Interview (CFI) to understand cultural idioms of distress, stigma, and family roles influencing presentation and recovery.
Note: DSM-5 Code 296.22.

Which cultural or contextual consideration is most relevant to diagnosing Liona’s depression accurately?

A. Using standardized Western instruments only
B. Ignoring cultural expressions of distress
C. Considering how cultural norms affect symptom expression and help-seeking
D. Focusing solely on biological explanations

Answer: B. Verbal assent from the adolescent and informed parental consent

Explanation: Ethical practice with minors requires parental consent plus adolescent assent, ensuring comprehension of benefits, risks, and alternatives. It maintains both autonomy and protection.
Note: DSM-5 Code 296.22.

Ethically, what must a clinician ensure before initiating pharmacotherapy for a minor?

A. No parental consent is required
B. Verbal assent from the adolescent and informed parental consent
C. Only adolescent consent is necessary
D. Treatment begins immediately without discussion