Meet Marcus
What's Marcus's age, and why was he referred?
27 years old, referred by his advisor after missing several deadlines
How many of the 9 DSM-5 criteria must be met, and for how long?
5 of 9, for at least 2 weeks.
What single disorder MUST be ruled out before starting an antidepressant?
Bipolar disorder (history of mania/hypomania)
What's the difference between passive and active suicidal ideation?
Passive = thoughts of death/no desire to live, no plan.
Active = a specific plan and/or intent to act.
+200 points Which one is Marcus experiencing?
Name two evidence-based therapies for MDD.
Answer: CBT and Behavioral Activation (also IPT).
Name two things Marcus stopped doing that signal withdrawal.
Answering friends' texts; quitting the intramural team he used to love. (Also: spending weekends in bed.)
Which two criteria are "gateway", one of them is required?
Depressed mood and anhedonia (loss of interest/pleasure).
Why does bipolar matter so much before treatment?
An antidepressant alone can trigger a manic episode in someone with bipolar, you need to screen for it first.
What's one thing you'd put in his safety plan?
crisis hotline (988), a trusted contact, removing means, a plan for when thoughts worsen, follow-up appointment.
Which therapy would you start with for Marcus's withdrawal, and why?
Behavioral Activation. It directly targets anhedonia and withdrawal by scheduling activities and breaking the "nothing matters" cycle.
His advisor referred him. What's one thing you'd want to ask the advisor that Marcus might not tell you?
About his functioning over time, when the decline started, whether grades dropped, whether he's withdrawn socially. Anything that validates the timeline.
+200
He lost 12 pounds without trying which criterion is that, and why does it matter?
Appetite/weight change. It matters because it's a physical sign of severity and helps rule in the diagnosis (and rules out purely "situational" stress).
Marcus's symptoms have lasted 5 months, why does that rule out persistent depressive disorder?
PDD requires symptoms for at least 2 years; 5 months is too short, and the episode is severe enough to meet MDD.
What can you share with his advisor, and what can't you and why?
You can share general updates with consent, but not session details, confidentiality limits apply unless there's imminent danger. (The advisor's referral doesn't automatically waive confidentiality.)
What's the relapse-prevention treatment for recurrent depression?
MBCT (Mindfulness-Based Cognitive Therapy) and/or maintenance treatment.
What's an important question you'd ask Marcus first, and why?
What's changed for you in the last few months?" to get his timeline and experience without leading him.
Marcus has no history of mania, but why does that single fact change his entire treatment plan
Because you must rule out bipolar before starting an antidepressant, otherwise you risk triggering a manic episode. That one fact determines whether it's safe to medicate at all.
What physical/medical causes should be ruled out, and how?
Thyroid problems, anemia, and other organic causes, via a physical exam and lab work (medical workup).
Marcus's passive suicidal thoughts don't meet the threshold for breaking confidentiality. But what would cross that threshold and what's your legal and ethical obligation in that moment?
Active ideation with a specific plan and intent or evidence he's at imminent risk of harming himself. Then you must take protective action: involve emergency services or a trusted contact, ensure he's not left alone, and document everything, because the duty to protect overrides confidentiality when there's imminent danger.
+200 points
For moderate-to-severe depression, what often beats either treatment alone?
Combined therapy + medication.