Case Study Of A Man With Severe Depression

Peter a 40 year old man, had become depressed following some money pressures which had put his livelihood and home under threat.

He had been to see his GP who had asked Peter to complete the self reporting Patient Health Questionnaire (PHQ9) to aid diagnosis and determine the level of depression. Peter scored 16 on this tool, which is indicative of a moderately severe depressive episode.

The GP suggested Peter should have a couple of weeks off work, make an appointment to see me for some psychological support and also prescribed the antidepressant drug Fluoxetine.

Peter did not attend the appointment given to him to attend my clinic, did not take anytime off work and did not use the prescription for medication. Peter later explained he had been rather shocked by his GP’s diagnosis as he felt that depression was a sign of weakness and had not considered himself to be a weak man. Therefore he decided he would try to sort himself out without any other intervention.

Unfortunately Peter was unable to deal with things himself and his depression worsened. When he attended the GP practice some 2 months later at the insistence of his wife, he was severely depressed and had a PHQ9 score of 25.

The GP immediately booked him into a space in my clinic and again urged Peter to start taking the Fluoxetine.

I saw Peter the following day and again assessed him to have a severe depression. I offered to commence a cognitive behavioural therapy approach to manage the depression and again suggested the antidepressant may be helpful to lift his mood. I explored his uncertainty around taking the medication and explained the potential side effects which may occur. Peter took the medication and after a week found that his symptoms were starting to lift. He experienced some gastro intestinal side effects, in particular, nausea which lasted for about 6 weeks but was manageable. I saw Peter on 4 further occasions when we worked on some behavioural activation work, which is known to be effective for depression, (NICE, 2009) and his mood began to lift further. His PHQ9 score dropped from 25 to 9, which is indicative of mild depression.

At the 6tth session, some 12 weeks later, Peter informed me he had stopped taking the Fluoxetine as it was causing some sexual dysfunction which was affecting his ability to achieve orgasm. Peter found this very difficult to talk about but explained that he and his wife fond this very frustrating and so therefore had decided to stop the medication.

I tried to explore this with Peter and advised that another antidepressant could be prescribed which may not have this particular side effect. I also explained that his choice to stop the antidepressant may also increase his chances of relapse. Peter was reluctant to explore these issues further and although he made another appointment to see me, he did not attend that appointment and failed to respond to any further communication.


On reflection, it would appear that Peter had several issues relating to his diagnosis of depression. Peter clearly had negative views about depression and what it meant for him as a person, unfortunately this is the case for many people as there is a great deal of stigma associated with depression.

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