A young 23-year-old lady had attempted suicide thrice in last one year. What is the cause of her condition? How do you diagnose and manage Major Depressive Disorder?

Major Depressive Disorder (MDD) is a common but serious mental health condition characterized by persistent sadness, loss of interest, and a range of cognitive, behavioral, and physical symptoms. Globally, an estimated 280 million people suffer from depression (WHO, 2021 – knowledge cutoff). Repeated suicide attempts, as seen in this 23-year-old woman, are a critical indicator of severe underlying distress and a potential medical emergency. Understanding the complex interplay of biological, psychological, and social factors is crucial for accurate diagnosis and effective management, aiming to reduce morbidity and mortality associated with this debilitating illness. Etiology of Repeated Suicide Attempts Multiple factors likely contribute to this patient’s condition. It’s rarely a single cause. These include: Biological Factors: Genetic predisposition, neurochemical imbalances (serotonin, dopamine, norepinephrine), and underlying medical conditions (e.g., hypothyroidism) can increase vulnerability. Psychological Factors: Past trauma (childhood abuse, neglect), adverse childhood experiences (ACEs), personality traits (e.g., perfectionism, low self-esteem), and maladaptive coping mechanisms. Social Factors: Stressful life events (relationship problems, financial difficulties, academic pressure), social isolation, lack of social support, and cultural factors. Psychiatric Comorbidities: Co-occurring mental health conditions like anxiety disorders, borderline personality disorder, substance use disorders, or eating disorders significantly increase suicide risk. The repeated attempts suggest a high level of distress and potentially a lack of effective coping strategies. It’s important to rule out any immediate precipitating factors or ongoing stressors. Diagnosis of Major Depressive Disorder Diagnosis is based on the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) or the International Classification of Diseases, 11th Revision (ICD-11). The key criteria for MDD 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, loss of 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. A thorough psychiatric evaluation is essential, including: Mental Status Examination (MSE): Assessing appearance, behavior, speech, mood, affect, thought process, thought content, cognition, and insight. Collateral Information: Gathering information from family members or close friends (with patient consent) to gain a more comprehensive understanding of the patient’s history and current functioning. Physical Examination & Laboratory Tests: To rule out medical causes of depressive symptoms (e.g., thyroid disorders, vitamin deficiencies). Suicide Risk Assessment: A detailed assessment of suicidal ideation, intent, plan, and access to means. Management of Major Depressive Disorder Management requires a multimodal approach: Pharmacological Interventions Selective Serotonin Reuptake Inhibitors (SSRIs): First-line treatment due to their relatively favorable side effect profile. Examples include fluoxetine, sertraline, paroxetine, citalopram, and escitalopram. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Effective for patients who do not respond to SSRIs or have co-occurring anxiety. Examples include venlafaxine and duloxetine. Tricyclic Antidepressants (TCAs): Older antidepressants with a higher risk of side effects, generally reserved for cases where SSRIs and SNRIs have failed. Monoamine Oxidase Inhibitors (MAOIs): Require strict dietary restrictions and have potential drug interactions, limiting their use. Medication should be initiated at a low dose and gradually titrated up based on response and tolerability. Close monitoring for side effects and suicidal ideation is crucial, especially during the initial weeks of treatment. Psychosocial Interventions Cognitive Behavioral Therapy (CBT): Helps patients identify and modify negative thought patterns and behaviors. Interpersonal Therapy (IPT): Focuses on improving interpersonal relationships and social functioning. Psychodynamic Therapy: Explores unconscious conflicts and past experiences. Family Therapy: Involves family members in the treatment process to improve communication and support. Support Groups: Provide a sense of community and shared experience. Crisis Management & Safety Planning Given the history of suicide attempts, a comprehensive safety plan is essential. This includes: Identifying warning signs of relapse. Developing coping strategies to manage distress. Listing supportive contacts (family, friends, therapists, crisis hotlines). Removing access to lethal means (e.g., firearms, medications). Establishing a plan for seeking immediate help in a crisis. Hospitalization may be necessary if the patient is actively suicidal or unable to maintain safety. Managing a young woman with a history of repeated suicide attempts requires a thorough assessment, accurate diagnosis of underlying MDD (or other co-morbid conditions), and a comprehensive, individualized treatment plan. A combination of pharmacological and psychosocial interventions, coupled with robust crisis management and safety planning, is crucial to reduce her risk of future attempts and improve her overall quality of life. Long-term follow-up and ongoing support are essential for maintaining recovery and preventing relapse.

What if the patient refuses medication?

Respecting patient autonomy is crucial. Explore the reasons for refusal (side effects, stigma, beliefs about medication). Offer psychoeducation, discuss alternative therapies, and collaborate to find a treatment plan the patient is comfortable with. Document the refusal and the rationale.

Major Depressive Disorder: Diagnosis & Management | UPSC Mains MEDICAL-SCIENCE-PAPER-II 2017

Etiology of Repeated Suicide Attempts

Multiple factors likely contribute to this patient’s condition. It’s rarely a single cause. These include:

Biological Factors: Genetic predisposition, neurochemical imbalances (serotonin, dopamine, norepinephrine), and underlying medical conditions (e.g., hypothyroidism) can increase vulnerability.
Psychological Factors: Past trauma (childhood abuse, neglect), adverse childhood experiences (ACEs), personality traits (e.g., perfectionism, low self-esteem), and maladaptive coping mechanisms.
Social Factors: Stressful life events (relationship problems, financial difficulties, academic pressure), social isolation, lack of social support, and cultural factors.
Psychiatric Comorbidities: Co-occurring mental health conditions like anxiety disorders, borderline personality disorder, substance use disorders, or eating disorders significantly increase suicide risk.

The repeated attempts suggest a high level of distress and potentially a lack of effective coping strategies. It’s important to rule out any immediate precipitating factors or ongoing stressors.

Diagnosis of Major Depressive Disorder

Diagnosis is based on the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) or the International Classification of Diseases, 11th Revision (ICD-11). The key criteria for MDD 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, loss of 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.

A thorough psychiatric evaluation is essential, including:

Mental Status Examination (MSE): Assessing appearance, behavior, speech, mood, affect, thought process, thought content, cognition, and insight.
Collateral Information: Gathering information from family members or close friends (with patient consent) to gain a more comprehensive understanding of the patient’s history and current functioning.
Physical Examination & Laboratory Tests: To rule out medical causes of depressive symptoms (e.g., thyroid disorders, vitamin deficiencies).
Suicide Risk Assessment: A detailed assessment of suicidal ideation, intent, plan, and access to means.

Management of Major Depressive Disorder

Management requires a multimodal approach:

Pharmacological Interventions

Selective Serotonin Reuptake Inhibitors (SSRIs): First-line treatment due to their relatively favorable side effect profile. Examples include fluoxetine, sertraline, paroxetine, citalopram, and escitalopram.
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Effective for patients who do not respond to SSRIs or have co-occurring anxiety. Examples include venlafaxine and duloxetine.
Tricyclic Antidepressants (TCAs): Older antidepressants with a higher risk of side effects, generally reserved for cases where SSRIs and SNRIs have failed.
Monoamine Oxidase Inhibitors (MAOIs): Require strict dietary restrictions and have potential drug interactions, limiting their use.

Medication should be initiated at a low dose and gradually titrated up based on response and tolerability. Close monitoring for side effects and suicidal ideation is crucial, especially during the initial weeks of treatment.

Psychosocial Interventions

Cognitive Behavioral Therapy (CBT): Helps patients identify and modify negative thought patterns and behaviors.
Interpersonal Therapy (IPT): Focuses on improving interpersonal relationships and social functioning.
Psychodynamic Therapy: Explores unconscious conflicts and past experiences.
Family Therapy: Involves family members in the treatment process to improve communication and support.
Support Groups: Provide a sense of community and shared experience.

Crisis Management & Safety Planning

Given the history of suicide attempts, a comprehensive safety plan is essential. This includes:

Identifying warning signs of relapse.
Developing coping strategies to manage distress.
Listing supportive contacts (family, friends, therapists, crisis hotlines).
Removing access to lethal means (e.g., firearms, medications).
Establishing a plan for seeking immediate help in a crisis.

Hospitalization may be necessary if the patient is actively suicidal or unable to maintain safety.

A young 23-year-old lady had attempted suicide thrice in last one year. What is the cause of her condition? How do you diagnose and manage Major Depressive Disorder?

Model Answer

Introduction

Etiology of Repeated Suicide Attempts

Diagnosis of Major Depressive Disorder

Management of Major Depressive Disorder

Pharmacological Interventions

Psychosocial Interventions

Crisis Management & Safety Planning

Conclusion

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