Full Answer Section

• Medical History: A review of any physical health conditions that could contribute to mood symptoms.
• Substance Use History: Assessment of alcohol and drug use, as substance abuse can exacerbate mood disorders.  

• Mental Status Examination: Evaluation of mood, affect, thought process, thought content, perception, cognition, and insight.  

• Diagnostic Interview: A structured clinical interview to gather information about the patient’s symptoms, severity, and duration.

Diagnosis:

Based on the patient’s presentation, a diagnosis of Major Depressive Disorder (MDD) is considered. MDD is characterized by a persistent depressed mood and a loss of interest or pleasure in activities, along with other symptoms such as fatigue, sleep disturbances, and changes in appetite.  

Treatment Plan:

A multimodal treatment approach is recommended for optimal outcomes:

1. Pharmacotherapy:

   • Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs are commonly used as first-line treatment for MDD. Examples include fluoxetine, sertraline, and escitalopram.  

   • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): SNRIs may be considered if SSRIs are ineffective. Examples include venlafaxine and duloxetine.  

   • Other Medications: In some cases, other medications, such as atypical antipsychotics or mood stabilizers, may be added to augment the treatment.

2. Psychotherapy:

   • Cognitive Behavioral Therapy (CBT): CBT focuses on identifying and modifying negative thought patterns and behaviors.  

   • Interpersonal Therapy (IPT): IPT focuses on improving interpersonal relationships and communication skills.  

   • Psychodynamic Therapy: Psychodynamic therapy explores unconscious conflicts and past experiences that may contribute to depressive symptoms.  

3. Lifestyle Interventions:

   • Regular Exercise: Physical activity can improve mood and reduce symptoms of depression.  

   • Healthy Diet: A balanced diet can support overall well-being and mental health.  

   • Adequate Sleep: Sufficient sleep is essential for mood regulation.  

   • Stress Management Techniques: Mindfulness, meditation, and yoga can help reduce stress and anxiety.  

Monitoring and Evaluation:

• Regular Follow-up: Monitor the patient’s progress through regular appointments.
• Symptom Rating Scales: Use standardized rating scales to assess the severity of symptoms and treatment response.
• Medication Side Effects: Monitor for side effects and adjust medication as needed.
• Treatment Adherence: Ensure the patient is adhering to the treatment plan.

By combining medication, psychotherapy, and lifestyle interventions, patients with MDD can experience significant improvement in their symptoms and quality of life.