Assessment and Management of Depressive Disorder: A Case Report of an Unmarried Adult

Assessment

The clinical interview and history provided a thorough overview of Client D.A.’s presenting symptoms, significant life events, and major impairments caused by her difficulties. The interview covered how she coped with her symptoms, any prior medical, psychological, or psychiatric help sought, her beliefs about her issues, her attitude toward these difficulties, and her cognitive functioning and mood at the time. Additionally, information was gathered on her family history, early development, educational history, psychosexual history, occupational history, and subjective ratings of her presenting complaints.^[11–12] During the interview, Client D.A. exhibited a range of depressive symptoms, including low mood, anhedonia, disrupted sleep patterns, changes in appetite, and persistent feelings of worthlessness. Her affect was congruent with her reported mood, and she displayed psychomotor agitation. Based on the clinical interview and the presentation of symptoms, Client D.A. met the criteria for Major Depressive Disorder (MDD), DSM-5 code 296.33 (recurrent, moderate). Further assessment, including the Minnesota Multiphasic Personality Inventory (MMPI-2), Rotter Incomplete Sentences Blank College Form (RISB), and Draw-A-Person (DAP) test, was warranted to rule out other potential contributors.

Given Client D.A.’s cultural background, particular attention was paid to culturally sensitive practices throughout therapy. For instance, therapeutic interventions were adapted to respect her family dynamics and cultural values, especially during interpersonal therapy (IPT) sessions, where family relationships played a key role. This ensured that the treatment aligned with her cultural beliefs and social context. As illustrated in Figure 1, Client D.A.’s risk factors included prolonged social isolation and unaddressed emotional trauma, while protective factors such as family support and willingness to engage in therapy was key to her recovery. Figure 2 outlines the cognitive model used to formulate her depressive symptoms, linking her distorted thoughts to behavioral and emotional consequences. These visual aids were presented during the initial sessions to help the client understand the formulation of her depression and guide therapeutic interventions.

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Figure 1:

Client’s risk and protective factors.

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Figure 2:

Client’s problem was formulated based on the cognitive model.

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Measurement

Structured clinical interviews for DSM-5 disorders: The Structured Clinical Interview for DSM-5 (SCID-5), developed by The American Psychiatric Association^[13] was utilized to diagnose MDD based on DSM-5 criteria. Mental health professionals widely use this semi-structured diagnostic interview to assess and diagnose psychiatric disorders, including mood disorders, anxiety disorders, psychotic disorders, and substance use disorders. The SCID-5 assesses both current and lifetime diagnoses of depression, providing a comprehensive evaluation of an individual’s clinical presentation across multiple axes, such as Axis I (clinical illnesses) and Axis II (personality disorders and intellectual disabilities). The administration of the SCID-5 takes approximately 10–15 minutes to complete the questionnaire, ensuring a thorough assessment of the specific criteria for each condition.

During the structured administration of the SCID-5 for MDD, each diagnostic criterion was systematically explored, allowing for an in-depth assessment of the nature, duration, and impact of the depressive symptoms experienced by Client D.A. The interview covered the severity of depressive symptoms, categorizing them as mild/moderate/severe based on the responses and overall clinical presentation. The comprehensive approach facilitated the exploration of potential comorbid conditions and the exclusion of other mood disorders or medical conditions that might mimic depressive symptoms. Client D.A. reported that her symptoms began in 2021 after learning of her romantic partner’s engagement to another woman. The SCID-5 depression module also included an examination of suicidal ideation, plans, and intent, although the client did not exhibit psychotic features. The severity specifier indicated the level of impairment, guiding treatment planning and intervention strategies. This instrument has been used in Nigeria by Okeafor and Okeafor^[14] among patients with stroke in Nigeria.

MMPI-2: The MMPI-2, developed by psychologists McKinley and Hathaway in 1943 and revised in 1989,^[15] is a comprehensive assessment tool designed to evaluate a wide range of psychological conditions and personality attributes, including psychopathologies such as depression, schizophrenia, and anxiety disorders. The MMPI-2 consists of 565 true-false items designed primarily for use with adults, providing an in-depth understanding of the client’s personality and aiding in the development of targeted treatment plans. It is widely used for clinical diagnosis, treatment planning, and psychological research, typically administered by trained mental health professionals like psychologists and psychiatrists. The MMPI-2’s psychometric properties are well established, demonstrating high reliability and validity. In Nigeria, the MMPI-2 has been utilized by clinical psychologists and researchers to assess and understand mental health issues within the Nigerian population, with adaptations to ensure cultural relevance and effectiveness. For instance, Tolulope et al.^[16] used the MMPI-2 among patients in a psychiatric hospital in Benin, Nigeria.

The client’s scores on the Trin and Vrin scales fall within the acceptable range, indicating a valid profile and suggesting the client approached the assessment with consistency and sincerity. Elevated scores on the F, FB, and FP scales (t-scores 106, 101, and 98, respectively) suggest potential issues with test-taking attitude. High elevations may indicate severe psychopathology or a tendency to present oneself in an overly negative light. The client scores on the L, K, and S scales (t-scores 47, 33, and 30, respectively) fall within the acceptable range, indicating a valid profile and suggesting that the client did not approach the assessment with excessive defensiveness.

Elevations were noted on all clinical scales, particularly on the psychotic personality scales. This indicates the presence of gross psychopathology, suggesting significant psychological distress and dysfunction. The client’s personality falls into the 8-7/7-8 code type. Individuals with this code type may experience a great deal of turmoil, exhibit hesitancy in admitting psychological problems, and lack effective defenses against discomfort. They may manifest symptoms such as depression, anxiety, tension, and poor judgment. Given the elevated scores on various scales, neurotic, psychotic, and personality disorder diagnoses are equally likely. There is an increased likelihood of a psychotic diagnosis, even in the absence of clear psychotic symptoms, as such symptoms may not be overtly present.

Rotter incomplete sentence blank—college form: The Rotter Incomplete Sentences Blank (RISB)—College Form was developed by Rotter.^[17] It measures an individual’s personality and emotional functioning by analyzing responses to incomplete sentences. The test is used to assess areas such as attitudes, motivations, and conflicts, providing insight into an individual’s psychological state. It is commonly used by clinical psychologists, counselors, and other mental health professionals in therapeutic and research settings. The RISB consists of 40 sentence stems that the respondent completes, with their responses being qualitatively analyzed for themes and quantitatively scored for overall adjustment. The test has demonstrated good reliability and validity, making it a useful tool for assessing psychological well-being in college students. This instrument has been used in Nigeria by Tamuno-opubo et al.^[18] on a 16-year-old client.

The RISB results suggest that Client D.A. experienced significant regret, worry, and emotional distress related to her past failures, unmet needs, and plans, particularly regarding marriage. She has a deep-seated fear of losing everything and expressed feelings of depression, inadequacy, loneliness, and helplessness, alongside intense self-directed rage over past mistakes. Client D.A. perceives marriage as unattainable.

Draw-a-person: The DAP test, developed by Goodenough^[19] and later expanded by Harris,^[20] is a projective personality assessment tool that evaluates an individual’s psychological state based on their drawing of a human figure. It measures aspects of personality, emotional functioning, and cognitive development through the analysis of drawing features such as detail, proportions, and overall quality. Used primarily by clinical psychologists, school psychologists, and counselors, the DAP test involves asking the subject to draw a person, which is then interpreted using standardized scoring systems. This instrument has been used in Nigeria by Tamuno-opubo et al.^[21] on assessment and management of conduct disorder of a 12-year-old.

The DAP test indicates that Client D.A. is highly sensitive about her appearance and exhibits aggressive and socially dominant behaviors as a compensatory defense mechanism for her feelings of inadequacy. She appears reluctant to engage with others, showing signs of evasiveness and possible maladaptive withdrawal, suggesting unease in social situations. Together, these results imply that Client D.A. struggles with profound emotional and social challenges, including potential depression, low self-esteem, and social anxiety.

Case conceptualization: Client D.A. is a 32-year-old unmarried female reported to have experienced persistent low mood, changes in sleep patterns, disruptions in appetite, feelings of worthlessness, and social withdrawal. The symptoms have been present for approximately two years, significantly impacting her daily functioning and overall quality of life. She reported a history of loneliness, feeling inferior, unimportant, and catered to by her caregivers. She also described a history of strained interpersonal relationships and distant family connections, suggesting a possible impact of early life stressors on her current mood. She also reported a lack of close social connections, leading to feelings of isolation and exacerbating the impact of the depressive symptoms. She stated that the abrupt end of her love relationship triggered the onset of her depressive episode approximately two years ago.

The client engaged in frequent negative self-talk and tended to interpret situations in a pessimistic and self-deprecating manners. Common cognitive distortions, including overgeneralization and catastrophizing, contributed to the maintenance of depressive symptoms. Her withdrawal from social interactions perpetuated a cycle of isolation, limiting positive reinforcement and support opportunities and bringing about “innovative helplessness”; “innovative helplessness” in the context of depression refers to a state in which the individual feels imprisoned in their condition. The client lacks the ability to explore novel strategies or ways to alleviate their symptoms. Individuals may experience a sense of being overwhelmed by their depressed moment, resulting in feelings of hopelessness and a reluctance to explore new strategies for managing their condition or seeking assistance. This can perpetuate the cycle of depression and hinder the individual’s ability to overcome their negative thoughts and behaviors.

Client D.A. was assessed for eligibility for treatment using the SCID-5, MMPI-2, RISB, and DAP. Following the initial assessment, she was assigned to treatment and evaluated psychologically regularly. In order to overcome this situation, it is necessary to motivate the client to question their ideas regarding their capacity to bring about change.^[22] It is crucial to offer them assistance and access to resources that enable them to investigate novel therapeutic alternatives and coping mechanisms.

Course of treatment: The treatment plan for Client D.A. was developed based on the comprehensive assessment, including the SCID-5, MMPI-2, RISB, and DAP tests. This multifaceted approach aimed to address the biological, psychological, and social factors contributing to her depressive symptoms, ultimately enhancing her overall well-being. Cognitive behavioral therapy (CBT) was a central component of the treatment plan. The primary objective of CBT was to identify and restructure negative thought patterns and cognitive distortions that perpetuated Client D.A.’s depressive symptoms. Techniques were introduced to challenge and modify these negative thoughts, promoting a more balanced and positive outlook. Additionally, CBT helped reintroduce previously enjoyed activities to restore a sense of fulfillment in her life. IPT was also incorporated to address the social isolation and strained interpersonal relationships that Client D.A. experienced. The therapy focused on improving her communication patterns, managing role transitions, and resolving interpersonal conflicts. This approach was crucial in rebuilding her social network and reducing feelings of loneliness.

Pharmacotherapy (fluoxetine, amitriptyline) was included to address the neurobiological factors contributing to MDD. In collaboration with a psychiatrist, appropriate antidepressant medication was prescribed for Client D.A. Regular follow-up appointments were scheduled to monitor her response to the medication, manage any side effects, and ensure adherence to the treatment regimen. To help manage stress and anxiety symptoms, mindfulness and relaxation techniques were introduced. Techniques such as mindfulness meditation and progressive muscle relaxation were implemented to assist Client D.A. in managing her anxiety and improving her overall sense of well-being. She was urged to acknowledge the significance of social support and engage in activities such as reconnecting with family members and participating in support groups or community activities as part of the treatment plan. This aimed to foster social connections and reduce isolation, providing her with a stronger support network.

Finally, developing a structured daily routine was emphasized to establish a healthy and balanced lifestyle. The routine prioritized self-care activities, physical exercise, and healthy sleep patterns. Additionally, activities that brought joy and a sense of fulfillment were integrated into her daily life, promoting a more positive and structured approach to her daily activities. The holistic treatment plan was designed to target and reduce the severity of depressive symptoms, increase social engagement, and rebuild interpersonal relationships. By enhancing her coping mechanisms and equipping her with effective strategies to manage stressors, the treatment plan aimed to guide Client D.A. toward symptom relief and improved mental well-being. Regular evaluation and revision of the treatment plan were essential to ensure its relevance and effectiveness in meeting her specific needs.

Throughout therapy, Client D.A. experienced a gradual reduction in depressive symptoms, including improved mood, better sleep patterns, and increased social engagement. She consistently provided feedback during weekly sessions, which was documented and used to assess emotional and functional progress. This feedback, collected through self-report questionnaires and reflective discussions, was crucial in adjusting interventions to meet her evolving needs. By mid-treatment, Client D.A. acknowledged that CBT helped her challenge negative thought patterns and re-engage in previously enjoyed activities, while IPT facilitated better communication with family members, reducing her sense of isolation. Mindfulness techniques also contributed to decreased anxiety and stress. The combined use of CBT and IPT effectively addressed her cognitive distortions and social isolation, with pharmacotherapy alleviating biological symptoms such as fatigue and insomnia. Progress was regularly monitored using the Hamilton Depression Rating Scale (HDRS), with ongoing improvements in her emotional and functional well-being.