Recognizing Recurrent Depression: A Clinical Case Study on Jerome
Depression should never be diagnosed from a single symptom like fatigue or low mood alone. In this case, a 35-year-old welder named Jerome presents with a pattern that looks like recurrent depressive symptoms layered with anxiety, insomnia, rising alcohol use, and heavy work stress — but that clinical picture doesn’t yet meet the full DSM-5-TR criteria for Major Depressive Disorder (MDD) based on what’s known so far. What it does call for is a full mental health workup: depression and suicide screening, a look at possible underlying medical causes, and a treatment plan built around Jerome specifically. Catching this kind of presentation early and treating it well improves recovery odds, lowers the chance of relapse, and helps prevent things like worsening substance use or suicide risk down the line.
Getting to Know Jerome’s Presentation
Jerome is 35, works as a welder, and lives with his partner and two young kids. He came into primary care describing persistent fatigue, low energy, a noticeable drop in motivation, and poor sleep that’s been going on for about six weeks. He’s clearly overwhelmed by pressure at work, though he’s managed to keep showing up and doing the job.
To deal with the insomnia, he’s started drinking more — from twice a week up to three beers every single evening. That shift matters clinically, because alcohol tends to make depression worse, disrupt sleep even further, and interfere with how well antidepressants work if they’re started later.
His history includes anxiety, panic attacks, and a moderately severe depressive episode five years ago that responded well to sertraline. He completed six months of treatment, stopped the medication, and stayed symptom-free without any ongoing follow-up after that. In today’s visit, he comes across as withdrawn, sad, and emotionally flat, though his physical exam doesn’t show anything abnormal.
Put together, this points strongly toward a recurrence of depression with anxiety running alongside it — but it’s not enough on its own to confirm MDD. That takes a closer look.
Starting the Clinical Assessment
The first move here isn’t a checklist — it’s building enough trust that Jerome will actually talk openly about his mood, his drinking, his stress at work, and what’s going on at home. That kind of trust is what makes an accurate assessment possible in the first place, and it also helps chip away at the stigma that often keeps people quiet about mental health.
A thorough psychiatric assessment for someone like Jerome should cover:
- Any prior episodes of depression or anxiety
- What’s currently stressing him out at work and at home
- Sleep quality and how well he’s functioning day to day
- Alcohol and other substance use
- Family history of psychiatric conditions
- How he responded to antidepressants in the past
- Whether he stuck with treatment before, and why or why not
- Suicidal thoughts, plans, or any past attempts
Since sertraline worked for him before, it’s worth understanding exactly why he stopped it — that detail could make a real difference for adherence if it gets restarted. Current guidance also pushes clinicians to weigh both psychological and physical contributors to symptoms like his, rather than assuming depression automatically explains the fatigue.
Tools That Support an Accurate Diagnosis
A good clinical interview goes further when it’s backed by validated screening tools that sharpen diagnostic accuracy and give a baseline to track progress against.
Physical Examination
Because fatigue and low mood can stem from a medical condition rather than depression itself, a full physical exam is a necessary step, not an optional one. That means checking general appearance and grooming, mood and affect, speech, neurological status, thyroid function, cardiovascular health, nutritional status, and vital signs. Fatigue in particular is nonspecific enough that ruling out medical causes has to happen before landing on a psychiatric diagnosis.
Standardized Screening Instruments
A handful of validated tools are commonly used in primary care for exactly this kind of presentation. The PHQ-9 measures how severe depressive symptoms are and tracks how treatment is going over time. The GAD-7 screens for generalized anxiety. The QIDS-SR gauges depression severity from the patient’s own perspective. The AUDIT-C flags hazardous alcohol use, which is directly relevant given Jerome’s recent drinking pattern.
A positive score on any of these should lead to a structured clinical interview against DSM-5-TR criteria — a questionnaire score alone was never meant to stand in for a full diagnostic conversation.
Suicide Risk Screening
Every patient presenting with depressive symptoms should be screened for suicide risk, whether or not they’ve brought it up themselves. A thorough assessment looks at current suicidal thoughts, any intent or planning behind them, past attempts, access to lethal means, protective factors in the patient’s life, and the strength of their family and social support. Making this a routine part of every visit, rather than something reserved for patients who volunteer it, is what actually catches risk early enough to intervene.
Medical Conditions That Can Look Like Depression
Before settling on a primary depressive disorder as the diagnosis, it’s worth ruling out physical conditions that can produce a nearly identical picture. That list includes hypothyroidism, iron deficiency anemia, vitamin B12 or D deficiency, diabetes, chronic liver or kidney disease, cardiovascular disease, chronic infections, neurological disorders, and obstructive sleep apnea. Medication-induced depression is also worth considering, though Jerome isn’t currently on any prescriptions.
His rising alcohol intake deserves particular attention here, since chronic alcohol use is a well-known driver of fatigue, disrupted sleep, anxiety, and worsening depression in its own right.
Does Jerome Actually Meet the Criteria for MDD?
Under DSM-5-TR, a diagnosis of Major Depressive Disorder requires at least five depressive symptoms present during the same two-week window, and at least one of those has to be depressed mood or a loss of interest or pleasure in things.
Right now, Jerome is showing depressed mood, fatigue, low energy, and insomnia. That’s four symptoms, and on its own, it isn’t enough to confirm MDD.
To get a complete picture, the clinical interview still needs to establish whether he’s also experiencing loss of interest or pleasure, changes in appetite or weight, feelings of guilt or worthlessness, trouble concentrating, psychomotor agitation or slowing, or recurrent thoughts of death or suicide. A full diagnosis depends on covering that ground first.
Building an Evidence-Based Treatment Plan
Treatment here needs to address Jerome’s mental health symptoms alongside whatever medical or behavioral factors turn out to be contributing.
Diagnostic Workup
A reasonable set of labs would include a complete blood count, thyroid-stimulating hormone, a comprehensive metabolic panel, vitamin B12 and D levels, iron studies if clinically warranted, blood glucose or HbA1c, and liver function tests given his increased drinking. Further testing should follow whatever the clinical picture suggests from there.
Medication
Since Jerome responded well to sertraline in the past, it’s a reasonable option to revisit once his current diagnosis is confirmed and any contraindications are ruled out. SSRIs remain a first-line choice for moderate depression and many anxiety disorders. Whatever medication path is chosen, patients benefit from knowing what to expect going in — improvement usually starts within two to four weeks, full benefit can take six to eight, early side effects often ease up over time, and stopping a medication abruptly without medical guidance isn’t advisable. That kind of upfront education tends to make a real difference in whether patients stick with treatment long enough for it to work.
Psychotherapy
The evidence consistently favors combining psychotherapy with medication for recurrent depression rather than relying on either alone. Cognitive behavioral therapy, behavioral activation, problem-solving therapy, and interpersonal therapy are all reasonable options, and referring to a licensed mental health professional early tends to pay off.
Lifestyle and Behavioral Changes
Lifestyle adjustments aren’t a substitute for treatment, but they meaningfully support recovery and lower the odds of relapse. Cutting back on or eliminating alcohol, building healthier sleep habits, staying physically active, eating a balanced diet, making room for activities that are actually enjoyable, leaning on family and social support, and practicing stress management all contribute to better mood, better sleep, and better treatment outcomes overall.
Following Up and Monitoring Progress
Close follow-up early in treatment gives the care team a chance to see what’s working and adjust course if it isn’t. That typically means checking back in within one to two weeks of starting treatment, keeping an eye on medication adherence and side effects, repeating the PHQ-9 and GAD-7 to track change over time, continuing to assess suicide risk at each visit, and staying in touch every two to four weeks until symptoms settle down. Patients should also leave with clear instructions to seek care right away if suicidal thoughts show up or symptoms take a turn for the worse.
Key Clinical Takeaways
Jerome’s presentation lines up closely with a recurrence of depression alongside anxiety and rising alcohol use, though confirming Major Depressive Disorder still requires more assessment. From a clinical standpoint, the priorities are:
- Run a full psychiatric assessment against DSM-5-TR criteria
- Screen with validated tools like the PHQ-9, GAD-7, and AUDIT-C
- Rule out medical conditions that can mimic depression
- Assess suicide risk at every visit, not just the first one
- Address hazardous alcohol use as part of the treatment plan itself
- Combine psychotherapy, lifestyle changes, and medication when appropriate
- Keep follow-up consistent to track response and catch relapse early
Frequently Asked Questions
What’s the most likely diagnosis for Jerome? His presentation points toward recurrent depressive symptoms with coexisting anxiety, insomnia, work stress, and increased alcohol use. Confirming Major Depressive Disorder still requires further clinical assessment against full DSM-5-TR criteria.
Which screening tool is most commonly used for depression in primary care? The PHQ-9 is one of the most widely used tools because it measures how severe depressive symptoms are, supports diagnosis, and helps track how treatment is progressing over time.
Why does alcohol use need to be assessed alongside depression? Alcohol can worsen depressive symptoms, disrupt sleep, blunt the effectiveness of antidepressants, and raise suicide risk. That makes screening for alcohol misuse a core part of any thorough depression assessment.
NU566 Unit 10 Discussion
Should lab testing happen before a depression diagnosis is confirmed? Yes. Labs help rule out conditions like hypothyroidism, anemia, vitamin deficiencies, diabetes, and liver disease, all of which can produce symptoms that look a lot like depression.
Why screen for suicide risk even if a patient hasn’t mentioned it? Patients sometimes hold back suicidal thoughts out of fear, stigma, or uncertainty about how it’ll be received. Making suicide risk assessment routine, rather than reactive, catches hidden risk factors early enough to act on them.
Conclusion
Depression often shows up as fatigue, low mood, low motivation, and disrupted sleep, but none of those symptoms should be read in isolation. Jerome’s case is a good example of why a full biopsychosocial assessment matters — paired with validated screening tools, suicide risk evaluation, and a look at possible medical causes — before a diagnosis gets confirmed. From there, a treatment plan that combines psychotherapy, medication where it’s indicated, lifestyle changes, and steady follow-up gives the best shot at real improvement, fewer relapses, and lasting recovery.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Aziz, R., Dunphy, L., & Bulfin, S. (2019). Mood disorders. In L. Dunphy, J. Winland-Brown, B. O. Porter, & D. J. Thomas (Eds.), Primary care: The art and science of advanced practice nursing—An interprofessional approach (5th ed., pp. 1100–1128). F.A. Davis.
Cook, M., & Wolz, A. (2018). Depression. In J. C. Cash & C. A. Glass (Eds.), Family practice guidelines (5th ed.). Springer Publishing. https://www.springerpub.com/family-practice-guidelines-9780826179463.html
NU566 Unit 10 Discussion
Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: Screening and diagnosis. American Family Physician, 98(8), 508–515. https://www.aafp.org/pubs/afp/issues/2018/1015/p508.html
U.S. Preventive Services Task Force. (2023). Screening for depression and suicide risk in adults: US Preventive Services Task Force recommendation statement. JAMA, 329(23), 2057–2067. https://jamanetwork.com/journals/jama/fullarticle/2806228