Diagnosis
This patient meets diagnostic criteria for Major Depressive Disorder (MDD), severe, with comorbid Generalized Anxiety Disorder (GAD), and Alcohol Use Disorder. 1, 2
Major Depressive Disorder - Severe
The PHQ-9 score of 22 indicates severe depressive symptomatology (scores 20-27 define severe depression), requiring immediate referral to psychiatry for diagnosis and treatment. 1
The patient meets DSM-IV criteria for MDD by endorsing at least 5 of 9 symptoms present nearly every day for the past year, including both core symptoms: 1, 3, 4
- Depressed mood (feeling down, depressed, hopeless) - score 3
- Anhedonia (little interest or pleasure in doing things) - score 3
- Sleep disturbance (trouble falling/staying asleep) - score 3
- Fatigue (feeling tired, having little energy) - score 3
- Poor appetite or overeating - score 3
- Feelings of worthlessness/failure - score 1
- Concentration difficulties - score 3
- Psychomotor retardation (moving/speaking slowly) - score 3
The patient explicitly reports that these symptoms cause "extremely difficult" functional impairment, meeting the DSM requirement for clinically significant distress and impairment in social and occupational functioning. 1, 3
Generalized Anxiety Disorder - Severe
The GAD-7 score of 18 (range 15-21) indicates severe anxiety, meeting criteria for GAD. 1 Scores ≥15 are considered severe levels of anxiety requiring psychiatric referral. 1, 2
The patient endorses the pathognomonic GAD symptom of excessive, uncontrollable worry ("worrying all the time") occurring nearly every day, along with: 1
- Feeling nervous/anxious - score 2 (more than half the days)
- Unable to stop/control worrying - score 3 (nearly every day)
- Worrying too much about different things - score 3 (nearly every day)
- Trouble relaxing - score 3 (nearly every day)
- Restlessness making it hard to sit still - score 3 (nearly every day)
- Easily annoyed/irritable - score 1 (several days)
- Feeling afraid something awful might happen - score 3 (nearly every day)
These symptoms have persisted for one year with marked functional impairment (loss of productivity, social isolation, inability to leave house). 1
Comorbidity Pattern
Approximately 50-75% of patients with MDD meet criteria for comorbid anxiety, and this patient exemplifies this common presentation. 5 The interconnection between irritability (endorsed by patient) and nervousness represents a strong trans-diagnostic association in MDD symptomatology. 6
Patients with MDD and comorbid anxiety have significantly worse psychosocial functioning, take longer to achieve remission, and are less likely to achieve remission than those with MDD alone. 5
Alcohol Use Disorder
The patient meets criteria for Alcohol Use Disorder given: 2
- Consumption of 36 beers weekly (approximately 5 beers daily) represents heavy alcohol use
- Self-reported use of alcohol as a coping mechanism for depression ("coped with by drinking alcohol")
- History of escalation (previously drinking hard liquor, now "cut down" to beer)
Medical causes of depressive and anxiety symptoms must be ruled out, including substance-induced mood disorder from alcohol use or withdrawal. 1, 2
ADHD Consideration
The patient's pre-existing ADHD diagnosis and current methylphenidate treatment must be considered, as: 7
- ADHD exhibits high comorbidity rates with anxiety and depressive disorders
- Concentration difficulties reported could represent ADHD symptoms, depressive symptoms, or both
- The complexity of comorbid ADHD with depression/anxiety poses significant diagnostic and treatment challenges
Critical Safety Assessment
The patient denied suicidal ideation (PHQ-9 item 9 scored 0), but given the severe depression score and emotional presentation (crying during encounter), ongoing suicide risk assessment is mandatory. 1, 3, 8 Any emergence of self-harm thoughts requires immediate emergency psychiatric evaluation. 1, 8
Additional Diagnoses to Consider
Before finalizing psychiatric diagnoses, rule out: 1, 2
- Thyroid dysfunction (obtain TSH, free T4)
- Vitamin deficiencies (B12, folate)
- Electrolyte abnormalities
- Medication-induced symptoms (methylphenidate can cause anxiety, mood changes)
- Alcohol withdrawal symptoms
- Delirium from metabolic causes