What is the diagnosis and treatment plan for a 33-year-old African American female patient presenting with symptoms of depression, including early morning wakefulness, tearfulness, guilt, irritability, insomnia, fatigue, and weight loss, who has a history of marital conflict and mistrust of her in-laws, and has previously been treated with fluoxetine (selective serotonin reuptake inhibitor)?

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Differential Diagnosis for Crystal Smith

  • Single Most Likely Diagnosis
    • Major Depressive Disorder (MDD): This diagnosis is the most likely due to Ms. Smith's symptoms of depressed mood, anhedonia, insomnia, fatigue, guilt, and irritability, which have been present for over 8 months. Her significant weight loss and difficulty performing daily activities also support this diagnosis.
  • Other Likely Diagnoses
    • Adjustment Disorder with Depressed Mood: This diagnosis is possible due to Ms. Smith's recent marital conflict and mistrust of her in-laws, which may have triggered her depressive symptoms.
    • Dysthymic Disorder: Although less likely, dysthymic disorder could be considered if Ms. Smith's depressive symptoms have been present for most of her life, with periods of worsening symptoms.
    • Postpartum Depression (PPD): Although Ms. Smith's children are school-age, it's possible that she experienced PPD in the past, which may have contributed to her current depressive symptoms.
  • Do Not Miss Diagnoses
    • Bipolar Disorder: Although Ms. Smith denies manic or hypomanic episodes, it's essential to rule out bipolar disorder, as antidepressant medication can trigger a manic episode.
    • Suicidal Ideation: Although Ms. Smith denies current suicidal ideation, her previous thoughts of "giving up" and being "better off dead" require close monitoring and assessment for suicidal risk.
    • Substance-Induced Mood Disorder: Although Ms. Smith denies substance use, it's crucial to rule out substance-induced mood disorders, as they can present with similar symptoms to MDD.
  • Rare Diagnoses
    • Schizoaffective Disorder: This diagnosis is less likely, but possible, if Ms. Smith's depressive symptoms are accompanied by psychotic symptoms, such as hallucinations or delusions.
    • Personality Disorder: Although Ms. Smith's symptoms are more consistent with MDD, a personality disorder, such as borderline personality disorder, could be considered if she exhibits a long-standing pattern of unstable relationships, emotional dysregulation, and impulsivity.
    • Thyroid Disorder: Hypothyroidism can present with depressive symptoms, fatigue, and weight loss, making it essential to rule out a thyroid disorder, especially if Ms. Smith's symptoms do not respond to treatment.

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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