A 45-year-old lady, after death of her husband 2 months back, is feeling lonely and remains aloof. (i) Enumerate the likely conditions. (ii) How will you diagnose and manage a major depressive disorder?

(i) Likely Conditions

Several conditions could present with symptoms similar to those described. These include:

• Normal Grief: The initial stages of grief can involve sadness, withdrawal, and difficulty concentrating. However, this typically improves over time.
• Prolonged Grief Disorder (PGD): Characterized by persistent and impairing grief reactions beyond what is culturally or religiously expected.
• Major Depressive Disorder (MDD): A mood disorder characterized by persistent sadness, loss of interest or pleasure, and other symptoms.
• Adjustment Disorder with Depressed Mood: An emotional or behavioral reaction to an identifiable stressor (in this case, the death of her husband) that causes significant distress or impairment.
• Anxiety Disorders: Generalized Anxiety Disorder or Panic Disorder can co-occur with grief and depression, manifesting as restlessness and avoidance.
• Post-Traumatic Stress Disorder (PTSD): If the circumstances surrounding the husband’s death were traumatic, PTSD could be a consideration.
• Medical Conditions: Hypothyroidism, vitamin deficiencies (B12, D), and other medical conditions can mimic depressive symptoms.

(ii) Diagnosis and Management of Major Depressive Disorder

Diagnosis

Diagnosis of MDD relies on established criteria, primarily the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The key criteria include:

• Presence of at least five symptoms during the same 2-week period, and represent a change from previous functioning. At least one of the symptoms must be either depressed mood or loss of interest or pleasure.
• Symptoms include: Depressed mood, diminished interest or pleasure (anhedonia), significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, difficulty concentrating, and recurrent thoughts of death or suicide.
• Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Symptoms are not attributable to the physiological effects of a substance or another medical condition.

Diagnostic Tools:

• Clinical Interview: A thorough psychiatric interview to assess symptoms, history, and risk factors.
• Standardized Questionnaires: Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HDRS) can quantify symptom severity.
• Physical Examination & Laboratory Tests: To rule out medical causes of depressive symptoms (e.g., thyroid function tests, complete blood count, vitamin levels).

Management

Management of MDD is multimodal, combining pharmacological and psychosocial interventions.

• Pharmacological Treatment:
• Selective Serotonin Reuptake Inhibitors (SSRIs): First-line treatment (e.g., Sertraline, Fluoxetine).
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Alternative if SSRIs are ineffective or poorly tolerated (e.g., Venlafaxine, Duloxetine).
• Tricyclic Antidepressants (TCAs): Older medications with more side effects, generally reserved for cases unresponsive to SSRIs/SNRIs.
• Monitoring: Regular monitoring for side effects and treatment response.
• Psychosocial Interventions:
• Cognitive Behavioral Therapy (CBT): Helps identify and modify negative thought patterns and behaviors.
• Interpersonal Therapy (IPT): Focuses on improving interpersonal relationships and social functioning.
• Grief Counseling: Provides support and guidance in processing grief.
• Support Groups: Connects individuals with similar experiences.
• Lifestyle Modifications: Encourage regular exercise, a healthy diet, and adequate sleep.
• Other Considerations:
• Electroconvulsive Therapy (ECT): Reserved for severe depression with psychotic features or treatment resistance.
• Hospitalization: May be necessary for patients with suicidal ideation or severe functional impairment.

Treatment Algorithm: Typically, an SSRI is initiated, and the patient is monitored for response. If there is no improvement after 6-8 weeks, the dose may be increased, or a different antidepressant may be tried. Psychotherapy is often initiated concurrently with medication.