psychology case study depression

Mental Health Case Study: Understanding Depression through a Real-life Example

Through the lens of a gripping real-life case study, we delve into the depths of depression, unraveling its complexities and shedding light on the power of understanding mental health through individual experiences. Mental health case studies serve as invaluable tools in our quest to comprehend the intricate workings of the human mind and the various conditions that can affect it. By examining real-life examples, we gain profound insights into the lived experiences of individuals grappling with mental health challenges, allowing us to develop more effective strategies for diagnosis, treatment, and support.

The Importance of Case Studies in Understanding Mental Health

Case studies play a crucial role in the field of mental health research and practice. They provide a unique window into the personal narratives of individuals facing mental health challenges, offering a level of detail and context that is often missing from broader statistical analyses. By focusing on specific cases, researchers and clinicians can gain a deeper understanding of the complex interplay between biological, psychological, and social factors that contribute to mental health conditions.

One of the primary benefits of using real-life examples in mental health case studies is the ability to humanize the experience of mental illness. These narratives help to break down stigma and misconceptions surrounding mental health conditions, fostering empathy and understanding among both professionals and the general public. By sharing the stories of individuals who have faced and overcome mental health challenges, case studies can also provide hope and inspiration to those currently struggling with similar issues.

Depression, in particular, is a common mental health condition that affects millions of people worldwide. Disability Function Report Example Answers for Depression and Bipolar: A Comprehensive Guide offers valuable insights into how depression can impact daily functioning and the importance of accurate reporting in disability assessments. By examining depression through the lens of a case study, we can gain a more nuanced understanding of its manifestations, challenges, and potential treatment approaches.

Understanding Depression

Before delving into our case study, it’s essential to establish a clear understanding of depression and its impact on individuals and society. Depression is a complex mental health disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities. It can affect a person’s thoughts, emotions, behaviors, and overall well-being.

Some common symptoms of depression include:

– Persistent sad, anxious, or “empty” mood – Feelings of hopelessness or pessimism – Irritability – Loss of interest or pleasure in hobbies and activities – Decreased energy or fatigue – Difficulty concentrating, remembering, or making decisions – Sleep disturbances (insomnia or oversleeping) – Appetite and weight changes – Physical aches or pains without clear physical causes – Thoughts of death or suicide

The prevalence of depression worldwide is staggering. According to the World Health Organization, more than 264 million people of all ages suffer from depression globally. It is a leading cause of disability and contributes significantly to the overall global burden of disease. The impact of depression extends far beyond the individual, affecting families, communities, and economies.

Depression can have profound consequences on an individual’s quality of life, relationships, and ability to function in daily activities. It can lead to decreased productivity at work or school, strained personal relationships, and increased risk of other health problems. The economic burden of depression is also substantial, with costs associated with healthcare, lost productivity, and disability.

The Significance of Case Studies in Mental Health Research

Case studies serve as powerful tools in mental health research, offering unique insights that complement broader statistical analyses and controlled experiments. They allow researchers and clinicians to explore the nuances of individual experiences, providing a rich tapestry of information that can inform our understanding of mental health conditions and guide the development of more effective treatment strategies.

One of the key advantages of case studies is their ability to capture the complexity of mental health conditions. Unlike standardized questionnaires or diagnostic criteria, case studies can reveal the intricate interplay between biological, psychological, and social factors that contribute to an individual’s mental health. This holistic approach is particularly valuable in understanding conditions like depression, which often have multifaceted causes and manifestations.

Case studies also play a crucial role in the development of treatment strategies. By examining the detailed accounts of individuals who have undergone various interventions, researchers and clinicians can identify patterns of effectiveness and potential barriers to treatment. This information can then be used to refine existing approaches or develop new, more targeted interventions.

Moreover, case studies contribute to the advancement of mental health research by generating hypotheses and identifying areas for further investigation. They can highlight unique aspects of a condition or treatment that may not be apparent in larger-scale studies, prompting researchers to explore new avenues of inquiry.

Examining a Real-life Case Study of Depression

To illustrate the power of case studies in understanding depression, let’s examine the story of Sarah, a 32-year-old marketing executive who sought help for persistent feelings of sadness and loss of interest in her once-beloved activities. Sarah’s case provides a compelling example of how depression can manifest in high-functioning individuals and the challenges they face in seeking and receiving appropriate treatment.

Background: Sarah had always been an ambitious and driven individual, excelling in her career and maintaining an active social life. However, over the past year, she began to experience a gradual decline in her mood and energy levels. Initially, she attributed these changes to work stress and the demands of her busy lifestyle. As time went on, Sarah found herself increasingly isolated, withdrawing from friends and family, and struggling to find joy in activities she once loved.

Presentation of Symptoms: When Sarah finally sought help from a mental health professional, she presented with the following symptoms:

– Persistent feelings of sadness and emptiness – Loss of interest in hobbies and social activities – Difficulty concentrating at work – Insomnia and daytime fatigue – Unexplained physical aches and pains – Feelings of worthlessness and guilt – Occasional thoughts of death, though no active suicidal ideation

Initial Diagnosis: Based on Sarah’s symptoms and their duration, her therapist diagnosed her with Major Depressive Disorder (MDD). This diagnosis was supported by the presence of multiple core symptoms of depression that had persisted for more than two weeks and significantly impacted her daily functioning.

The Treatment Journey

Sarah’s case study provides an opportunity to explore the various treatment options available for depression and examine their effectiveness in a real-world context. Supporting a Caseworker’s Client Who Struggles with Depression offers valuable insights into the role of support systems in managing depression, which can complement professional treatment approaches.

Overview of Treatment Options: There are several evidence-based treatments available for depression, including:

1. Psychotherapy: Various forms of talk therapy, such as Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT), can help individuals identify and change negative thought patterns and behaviors associated with depression.

2. Medication: Antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs), can help regulate brain chemistry and alleviate symptoms of depression.

3. Combination Therapy: Many individuals benefit from a combination of psychotherapy and medication.

4. Lifestyle Changes: Exercise, improved sleep habits, and stress reduction techniques can complement other treatments.

5. Alternative Therapies: Some individuals find relief through approaches like mindfulness meditation, acupuncture, or light therapy.

Treatment Plan for Sarah: After careful consideration of Sarah’s symptoms, preferences, and lifestyle, her treatment team developed a comprehensive plan that included:

1. Weekly Cognitive Behavioral Therapy sessions to address negative thought patterns and develop coping strategies.

2. Prescription of an SSRI antidepressant to help alleviate her symptoms.

3. Recommendations for lifestyle changes, including regular exercise and improved sleep hygiene.

4. Gradual reintroduction of social activities and hobbies to combat isolation.

Effectiveness of the Treatment Approach: Sarah’s response to treatment was monitored closely over the following months. Initially, she experienced some side effects from the medication, including mild nausea and headaches, which subsided after a few weeks. As she continued with therapy and medication, Sarah began to notice gradual improvements in her mood and energy levels.

The CBT sessions proved particularly helpful in challenging Sarah’s negative self-perceptions and developing more balanced thinking patterns. She learned to recognize and reframe her automatic negative thoughts, which had been contributing to her feelings of worthlessness and guilt.

The combination of medication and therapy allowed Sarah to regain the motivation to engage in physical exercise and social activities. As she reintegrated these positive habits into her life, she experienced further improvements in her mood and overall well-being.

The Outcome and Lessons Learned

Sarah’s journey through depression and treatment offers valuable insights into the complexities of mental health and the effectiveness of various interventions. Understanding the Link Between Sapolsky and Depression provides additional context on the biological underpinnings of depression, which can complement the insights gained from individual case studies.

Progress and Challenges: Over the course of six months, Sarah made significant progress in managing her depression. Her mood stabilized, and she regained interest in her work and social life. She reported feeling more energetic and optimistic about the future. However, her journey was not without challenges. Sarah experienced setbacks during particularly stressful periods at work and struggled with the stigma associated with taking medication for mental health.

One of the most significant challenges Sarah faced was learning to prioritize her mental health in a high-pressure work environment. She had to develop new boundaries and communication strategies to manage her workload effectively without compromising her well-being.

Key Lessons Learned: Sarah’s case study highlights several important lessons about depression and its treatment:

1. Early intervention is crucial: Sarah’s initial reluctance to seek help led to a prolongation of her symptoms. Recognizing and addressing mental health concerns early can prevent the condition from worsening.

2. Treatment is often multifaceted: The combination of medication, therapy, and lifestyle changes proved most effective for Sarah, underscoring the importance of a comprehensive treatment approach.

3. Recovery is a process: Sarah’s improvement was gradual and non-linear, with setbacks along the way. This emphasizes the need for patience and persistence in mental health treatment.

4. Social support is vital: Reintegrating social activities and maintaining connections with friends and family played a crucial role in Sarah’s recovery.

5. Workplace mental health awareness is essential: Sarah’s experience highlights the need for greater understanding and support for mental health issues in professional settings.

6. Stigma remains a significant barrier: Despite her progress, Sarah struggled with feelings of shame and fear of judgment related to her depression diagnosis and treatment.

Sarah’s case study provides a vivid illustration of the complexities of depression and the power of comprehensive, individualized treatment approaches. By examining her journey, we gain valuable insights into the lived experience of depression, the challenges of seeking and maintaining treatment, and the potential for recovery.

The significance of case studies in understanding and treating mental health conditions cannot be overstated. They offer a level of detail and nuance that complements broader research methodologies, providing clinicians and researchers with invaluable insights into the diverse manifestations of mental health disorders and the effectiveness of various interventions.

As we continue to explore mental health through case studies, it’s important to recognize the diversity of experiences within conditions like depression. Personal Bipolar Psychosis Stories: Understanding Bipolar Disorder Through Real Experiences offers insights into another complex mental health condition, illustrating the range of experiences individuals may face.

Furthermore, it’s crucial to consider how mental health issues are portrayed in popular culture, as these representations can shape public perceptions. Understanding Mental Disorders in Winnie the Pooh: Exploring the Depiction of Depression provides an interesting perspective on how mental health themes can be embedded in seemingly lighthearted stories.

The field of mental health research and treatment continues to evolve, driven by the insights gained from individual experiences and comprehensive studies. By combining the rich, detailed narratives provided by case studies with broader research methodologies, we can develop more effective, personalized approaches to mental health care. As we move forward, it is essential to continue exploring and sharing these stories, fostering greater understanding, empathy, and support for those facing mental health challenges.

References:

1. World Health Organization. (2021). Depression. Retrieved from https://www.who.int/news-room/fact-sheets/detail/depression

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

3. Beck, A. T., & Alford, B. A. (2009). Depression: Causes and treatment. University of Pennsylvania Press.

4. Cuijpers, P., Quero, S., Dowrick, C., & Arroll, B. (2019). Psychological treatment of depression in primary care: Recent developments. Current Psychiatry Reports, 21(12), 129.

5. Malhi, G. S., & Mann, J. J. (2018). Depression. The Lancet, 392(10161), 2299-2312.

6. Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., … & Schatzberg, A. F. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2(1), 1-20.

7. Sapolsky, R. M. (2004). Why zebras don’t get ulcers: The acclaimed guide to stress, stress-related diseases, and coping. Holt paperbacks.

8. Yin, R. K. (2017). Case study research and applications: Design and methods. Sage publications.

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• > Journals
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Article contents

• Key learning aims

Background to the case study

Key practice points, data availability statement, author contributions, financial support, conflicts of interest, ethical standards, cbt for difficult-to-treat depression: single complex case.

Published online by Cambridge University Press:  11 August 2022

Cognitive behavioural therapy (CBT) is an effective treatment for depression but a significant minority of clients are difficult to treat: they are more likely to have adverse childhood experiences, early-onset depression, co-morbidities, interpersonal problems and heightened risk, and are prone to drop out, non-response or relapse. CBT based on a self-regulation model (SR-CBT) has been developed for this client group which incorporates aspects of first, second and third wave therapies. The model and treatment components are described in a concurrent article (Barton et al ., 2022). The aims of this study were: (1) to illustrate the application of high dose SR-CBT in a difficult-to-treat case, including treatment decisions, therapy process and outcomes, and (2) to highlight the similarities and differences between SR-CBT and standard CBT models. A single case quasi-experimental design was used with a depressed client who was an active participant in treatment decisions, data collection and interpretation. The client had highly recurrent depression with atypical features and had received several psychological therapies prior to receiving SR-CBT, including standard CBT. The client responded well to SR-CBT over a 10-month acute phase: compared with baseline, her moods were less severe and less reactive to setbacks and challenges. Over a 15-month maintenance phase, with approximately monthly booster sessions, the client maintained these gains and further stabilized her mood. High dose SR-CBT was effective in treating depression in a client who had not received lasting benefit from standard CBT and other therapies. An extended maintenance phase had a stabilizing effect and the client did not relapse. Further empirical studies are underway to replicate these results.

(1) To find out similarities and differences between self-regulation CBT and other CBT models;

(2) To discover how self-regulation CBT treatment components are delivered in a bespoke way, based on the needs of the individual case;

(3) To consider the advantages of using single case methods in routine clinical practice, particularly with difficult-to-treat cases.

CBT based on a self-regulation model (SR-CBT) is a cognitive behavioural therapy for difficult-to-treat depression (McAllister-Willams et al ., Reference McAllister-Williams, Arango, Blier, Demyttenaere, Falkai, Gorwood, Hopwood, Javed, Kasper, Malhi, Soares, Vieta, Young, Papadopoulos and Rush 2020 ; Rush et al ., Reference Rush, Sackeim, Conway, Bunker, Hollon, Demyttenaere, Young, Aaronson, Dibué, Thase and McAllister-Williams 2022 ). The model and treatment components are described in a concurrent article (Barton et al ., Reference Barton, Armstrong, Robinson and Bromley 2022 ) and readers are encouraged to read that article for more details about the theoretical framework and how the treatment components are derived from it. The aim of this article is to illustrate the application of SR-CBT in a difficult-to-treat case of depression, in particular how the treatment components were organized and delivered, and how these influenced the process and outcome of therapy. SR-CBT has 10 treatment components and a key part of the approach is individualizing therapy based on the case formulation. Individualizing means varying the sequence, combination and dose of the treatment components, based on client need – it does not mean drifting from the therapist actions prescribed in the components.

The client in question was an active participant in the research process. She suffered from highly recurrent depression, with atypical mood fluctuations, and had received several treatments over the previous 13 years, including anti-depressant medication, computer-assisted CBT, counselling, psychodynamic psychotherapy, group-based mindfulness-based CBT, individual CBT, and intermittent care from a community mental health team and crisis team. She had received temporary but not lasting benefit from these interventions, gaining support, psychoeducation and coping skills, but not lasting remission from depression. She concurred that her depression was difficult to treat, acknowledging that there had been difficulties for both her and her previous therapists. Following assessment at the Centre for Specialist Psychological Therapies, the client was given the choice between a further course of standard CBT and a course of SR-CBT. She was given information, had an opportunity to ask questions and chose SR-CBT, explaining that the previous CBT been helpful but not lasting, and she would prefer to try a novel treatment.

At the time of the assessment, the client had been keeping a daily mood diary over the previous 16 months (514 days), during which time she had received a course of standard CBT (15 sessions), anti-depressant medication (ADM) and support from a community mental health team (CMHT). The daily diary created an opportunity for a baseline phase against which the SR-CBT could be compared and tested. The opportunity for a quasi-experiment was only recognized at this point, so the case study was limited to the mood measure that the client had been using in her previous care. The sequence of SR-CBT delivered after CBT, ADM and CMHT was not randomized or open to experimental control. Nevertheless, this case study is a good example of naturalistic practice-based evidence, with a high level of collaboration and participation from the service user. She recognized the value of continuing to complete the mood diary as a way of comparing SR-CBT with previous treatments, and was supportive of her treatment being summarized in this article, taking an active role in ensuring confidentiality within the write-up (several personal details are anonymized). She declined the opportunity to be a co-author but provided feedback on drafts and was satisfied with how the therapy had been summarized and discussed. The first author (S.B.) was the therapist, and he received monthly supervision throughout from the second author (P.A.).

Demographics and mental health history

Evelyn (psydonym) was a 52-year-old married woman with two grown-up daughters from a previous marriage. She first presented to mental health services aged 39, diagnosed with recurrent depressive disorder. She reported occasional episodes of depression as an adolescent that became more frequent and problematic in her late 20s and 30s. Evelyn’s marriage broke down when she was 42 and this precipitated an intense experience of personal failure, a severe depressive episode and a serious suicide attempt. In the subsequent 10 years, Evelyn experienced intermittent severe depressive episodes within the same phasic pattern. During periods of milder depression, Evelyn could be energized and engaged in her work as managing director of a company. These phases fell short of the threshold for hypomania: bipolar II disorder was not diagnosed, but psychiatric evaluation suggested an atypical phasic pattern of alternating mild, moderate and severely depressed moods with a high level of unpredictability from one day to the next.

Treatment phases

Up to 30 sessions is the usual dose of SR-CBT for clients with difficult-to-treat depression, and Evelyn received 27 sessions of SR-CBT over a 10-month acute phase (306 days). Her pre-treatment Patient Health Questionnaire score was 19 (PHQ-9; Kroenke et al ., Reference Kroenke, Spitzer and Williams 2001 ) indicating moderate depression symptoms, and her GAD-7 score was 5, confirming depression as the primary problem (Spitzer et al ., Reference Spitzer, Kroenke, Williams and Löwe 2006 ). Evelyn’s moods were subject to a lot of fluctuations and this pattern is depicted in a graph of her daily mood ratings (Fig.  1 ). The ratings were made on the following 11-point scale, with higher numbers representing milder depression: 7–10, OK mood; 5–6, very depressed; 4, suicidal wishes; 0–3, actively suicidal.

Figure 1. Evelyn’s daily mood ratings across treatment phases.

Evelyn was at heightened risk of relapse due to adverse childhood experiences, early onset depression, multiple previous episodes and unstable remission (Bockting et al ., Reference Bockting, Hollon, Jarrett, Kuyken and Dobson 2015 ). For this reason, she was offered a maintenance phase of monthly booster sessions after the acute phase was completed, with the goal of maintaining progress and staying well (Jarrett et al ., Reference Jarrett, Kraft, Doyle, Foster, Eaves and Silver 2001 ). This was initially expected to last 6 months, but it was extended to 15 months (15 sessions, 463 days) to accommodate Evelyn’s learning process and heightened risk. Evelyn continued to take anti-depressant medication and have intermittent CMHT support during both phases of SR-CBT.

Treatment process

Emphasis was placed on the self-regulation skills that Evelyn most needed to develop, based on her case formulation. To provide an overview of when and how the components were delivered, the acute and maintenance phases have been combined in the following summary. The number of sessions in which each component formed a significant part are presented in a cumulative plot in Fig.  2 . Sessions usually combined more than one treatment component (mean = 2.77 per session). The way each component was delivered, and the number of sessions in which they formed a part, are described below.

Figure 2. SR-CBT treatment components: cumulative number of sessions in which each component was delivered.

Alliance building (10/42 sessions)

An effective working alliance was established with Evelyn over the first five sessions. She was trusting and respectful and the personal alliance formed easily. The task alliance, reflected in alignment on target problems, goals and therapy tasks, was more challenging to develop, and there were three barriers (Barton et al ., Reference Barton, Armstrong, Wicks, Freeman and Meyer 2017 ; Cameron et al ., Reference Cameron, Rodgers and Dagnan 2018 ). Firstly, Evelyn was ambivalent about receiving further CBT and unsure whether it would differ from her previous therapy. Her initial motivation came from a sense of obligation to her husband, who encouraged her to try new therapies. Evelyn was not optimistic that SR-CBT would produce benefits that were different or greater than previous therapies. Secondly, Evelyn’s mood disorder was highly persistent with several recurrent major episodes and an atypical pattern of mood fluctuations. Even if she responded to SR-CBT, she would have heightened risk of relapse (Wojnarowski et al ., Reference Wojnarowski, Firth, Finegan and Delgadillo 2019 ). Thirdly, Evelyn had suffered adverse childhood experiences in her birth family for which she felt partly responsible. She felt uncomfortable discussing herself, and was particularly reluctant to discuss early experiences in case she was perceived to be blaming her parents.

The therapist’s response was to guide discovery about each of these issues, making them explicit and investing time to reach an aligned position. The therapist sought to differentiate SR-CBT from standard CBT, encouraging Evelyn to find out if it was similar or different by committing to a small number of sessions initially. This increased Evelyn’s agency to engage in the therapy, without the therapist taking too much responsibility for change. The therapist also emphasized the need for two phases of treatment, the first to improve Evelyn’s mood and the second to sustain those changes. The risk of relapse was acknowledged at the outset, with a pro-active approach emphasizing that staying well depended on applying self-regulation skills that could be learned during treatment. Finally, the therapist acknowledged that a strong relationship was needed to discuss painful childhood experiences, and Evelyn did not need to decide at the start of therapy whether she wanted to do this later. These conversations had an alliance-strengthening effect, sufficient to proceed with the other treatment components. Throughout treatment, the therapist had to be robust in maintaining the task alliance to keep the therapy sufficiently change-focused.

Treatment rationale (14/42 sessions)

The treatment rationale in SR-CBT is to reflect on mood fluctuations, differentiating depressed and less-depressed moods and using this to leverage change. Depressed moods help to formulate how depression is maintained; less-depressed moods help to find a path out of depression. Evelyn readily accepted that there were a lot of fluctuations in her moods. She found it particularly frustrating, and bewildering, that her moods could plummet from mild to severe in a short space of time with no apparent trigger. She accepted the logic that less-depressed moods could help to find a path out of depression, but in practice she would default to discussing depression, trying to find out what had triggered it so that she could avoid those triggers. Avoiding triggers was one of the strategies she had learned in previous treatments. In Evelyn’s case, this strategy was maintaining behavioural avoidance and rumination (e.g. ‘why do these keep happening?’). She gradually accepted that she could not always discover what the triggers were, and also came to realize that avoiding triggers was not the best strategy, because they were difficult to predict and attempting to do so maintained an avoidant orientation: trying to dodge undetermined hazards, rather than influencing situations in a preferred direction (Quigley et al ., Reference Quigley, Wen and Dobson 2017 ).

Over the first five sessions, Evelyn was socialized to key features of the self-regulation model. The model proposes that depression is perpetuated by repeated interactions of self-identity disruption, impaired motivation, disengagement, rumination, intrusive memories and passive life-goals. The repeated interaction of these processes maintains depression like a traffic gridlock (Barton and Armstrong, Reference Barton and Armstrong 2019 ; Teasdale and Barnard, Reference Teasdale and Barnard 1993 ). Figure  3 presents Evelyn’s formulation which was built up over several sessions.

Figure 3. Evelyn’s case formulation.

Evelyn’s self-identity was narrowly invested in taking responsibility for others through her work as a managing director. This was a positive self-representation in the sense that it provided self-definition, value and purpose. Evelyn ascribed importance to doing her job well and was highly invested in that goal. This does not mean that she had consistently positive beliefs about doing a good job; in fact, these fluctuated a great deal. She experienced phases of work going reasonably well when she reported her mood to be ‘OK’, but small setbacks at work (real or perceived) had a disproportionate effect on her mood. She could switch rapidly into a self-loathing, unmotivated, withdrawn, ruminative state, pre-occupied with memories of letting others down and uninterested in planning for the future. When Evelyn’s depression was milder, she would engage in work tasks with some interest and a felt-sense of obligation, sometimes over-working, joining in with others and experiencing some job satisfaction. She recognized that her attention was more externally focused on these occasions, and she was more able to think clearly and make decisions.

The treatment rationale was revisited regularly throughout therapy, particularly when Evelyn suffered setbacks and became despondent about change. When this happened, the therapist would re-focus attention on less-depressed moods and encourage Evelyn to keep influencing her motivation, actions and cognition. To effect change, sufficient emphasis has to be placed on less-depressed experiences, and to achieve this the treatment rationale usually has to be revisited regularly.

Approach motivation (18/42 sessions)

Approach motivation is often delivered in combination with active engagement (see below). The aim is to stimulate approach impulses which are usually attenuated during depression with reduced positive anticipation, lower reward expectancies and weakened interest in desired outcomes (Sherdell et al ., Reference Sherdell, Waugh and Gotlib 2012 ). When reflecting on Evelyn’s less-depressed moods, the therapist questioned her motivational impulses and intentions; for example, when she felt some satisfaction after a particular work meeting. This increased the explicitness of Evelyn’s desires to support the staff that worked in her company, to whom she felt very responsible. Rather than focusing on responsibility beliefs, the therapist asked what Evelyn would like to happen in her organization, and how she would like key staff to develop. These desires were elaborated in a lot of detail and they helped to generate reasons for action; for example, to influence work culture and strategic direction.

Another example was bringing attention to what Evelyn needed when she felt negative emotions; for example, upset, guilt, sadness or anger. Her tendency was to suppress negative emotions because they would often activate depressing thoughts and provoke rumination. She had not considered emotions as signalling needs, for example, the need for self-soothing, forgiveness, support, grieving, communication, fairness, etc. Evelyn was not accustomed to reflecting on her needs and desires in this way, initially appraising it as selfish. This was unfamiliar and uncomfortable for her – even dystonic at times – and took a long time to make sense and sit more comfortably. Attending to needs and desires is self-compassionate: it signals the value of responding to one’s suffering and attempting to alleviate it, and of taking desires seriously and wanting to realize them. Repeated attention to Evelyn’s needs and desires helped to generate reasons for action and, over an extended period, reasons to act gradually became impulses for action.

Active engagement (21/42 sessions)

The goal of active engagement is to increase clients’ interaction with tasks and other people, with engagement targeted in situations where the client tends to disengage, withdraw and/or avoid (Ottenbreit et al ., Reference Ottenbreit, Dobson and Quigley 2014 ). There is a big emphasis on experimentation, with clients encouraged to try out new ways of interacting, including how they relate to themselves. The focus is on setting goals to influence preferred outcomes and aligning those goals with needs and desires. Consequently, the output of approach motivation is often used to plan experiments within active engagement.

In Evelyn’s therapy, 50% of the sessions involved planning a behavioural experiment to be conducted before the next session, and this would often relate to a work commitment that Evelyn’s secretary had booked in, or a personal engagement that her husband had arranged for them. It was normal for Evelyn to be dreading these and feel like withdrawing from them. From session 6 onwards, the repeating therapeutic pattern was exploring prospectively what Evelyn would like to happen in those situations. Time was taken to plan how she wanted to approach the situation, emphasizing how she would interact and communicate with others, to try to influence what she would like to happen. She would also consider which mindset she needed to be in before, during and after the situation, in particular where to place her attention and how to keep preferences in mind. Sessions would end with Evelyn stating her preferred outcomes, not her predictions, and the experiment was to find out if and how she could influence those preferences. A de-brief was planned for the next session.

Examples include feeling despondent about not having sufficient administrative support in her office, even though she was the managing director of the company. When feeling depressed, it did not occur to Evelyn that she had the authority and influence to hire more staff, imagining that this would be blocked by red tape that was out of her control. The therapist dis-attended to Evelyn’s negative predictions and kept attention on what she would like to happen in this situation. With some reluctance and difficulty, Evelyn slowly worked back from the desired outcome and, over a number of weeks, the staffing was increased. Another example was dreading a visit to see her elderly parents, feeling like cancelling on the pretence of ill-health. The therapist enquired about the best and worst memories of visiting her parents, and this helped Evelyn to identify what she was most dreading: feeling trapped in their home, unable to leave (see self-organization section). By staying focused on what she would like to happen (e.g. having her own space, going out when she wanted), Evelyn developed a plan to stay in a local hotel and let her parents know in advance that she was increasing physical exercise. These possibilities had not previously occurred to Evelyn, and overall they contributed to a more tolerable family visit.

Evelyn struggled with active engagement for several months, preferring to talk about negative experiences that had occurred in the previous week, and was sometimes frustrated that the therapist did not pay much attention to her negative predictions. The personal alliance was sufficiently strong to withhold this, so the therapist kept the task alliance as the priority (i.e. change-focus). After 6 months of slow learning, a threshold was reached and Evelyn started to internalize the active engagement process that she had applied across several experiments. When she paid attention to her preferred outcomes, and formed an intention to bring them about, she was usually able to influence them in some way, even if it was not in the way she had expected.

Mental freedom (19/42 sessions)

The aim of mental freedom is to develop a good self-mind relationship with reflective capacity, attentional skills and productive questioning. The first step is to increase awareness of the difference between rumination and reflection and this occurred in the first six sessions when the treatment rationale and initial formulation was developed. Evelyn accepted that rumination was unhelpful but she did not always recognize when it was happening (Watkins and Roberts, Reference Watkins and Roberts 2020 ). When her mood lifted, she was usually able to reflect back on her experiences and recognize that rumination had occurred. It took several months for Evelyn to become aware of rumination when it was happening in the moment, and then she felt minimal control over it. As her reflective capacity increased, Evelyn developed more attentional skills. This grew out of the recognition that she tended to be self-focused in depressed moods and more externally focused in less-depressed moods. External focus of attention became a regular part of active engagement. This gradually gave her a tool to use when feeling more depressed, choosing to place her attention externally, when she remembered to do so. This was not sufficient to prevent all depression and rumination, but it had a beneficial effect and was the beginning of Evelyn learning how to influence her cognition during depressed moods.

The intervention that had greatest impact was recognizing the unhelpfulness of the questions she asked herself when feeling depressed, such as: ‘what’s the point?’, ‘why bother?’, ‘why can’t I be normal like everyone else?’, etc. These thoughts indicated how distressed, frustrated and angry Evelyn could become with herself. When her mood was less depressed, Evelyn brought these questions to mind in cognitive experiments within therapy sessions: the presence of the questions depressed her mood, brought negative thoughts to mind and led to unhelpful answers. Evelyn recognized their unhelpfulness, but didn’t know how to think differently, especially when feeling depressed. With the therapist’s guidance, she was able to experiment with different types of question such as ‘how can I help myself right now?’, ‘what do I need to do next?’, ‘who can I talk to?’. Evelyn recognized that these were more helpful, concrete and practical questions, giving her ideas for action, and that this was a better way to respond when feeling down. She started monitoring her questions at work, particularly when feeling burdened or guilty, and there was a gradual shift from less to more helpful questioning (e.g. ‘why do I keep messing up?’ became ‘did I make a mistake?’). The challenge was helping Evelyn to access reflective thinking when she most needed it, when her mood was 6/10 or less. Initially she was only able to apply these skills when her mood was 7/10 or greater, and this became one of the key aims of relapse prevention and staying well.

Self-organization (5/42), goal organization (2/42) and memory integration (2/42 sessions)

In the self-regulation model, vulnerability to depression results from the under-development of positive self-representations and their associated self-regulatory capacities, rather than the presence negative beliefs. The main aim of self-organization is to strengthen, diversify and re-structure positive self-representations. The main aim of memory integration is to elaborate positive recollections to increase their memorability and accessibility, when possible making explicit links to positive self-representations. The main aim of goal-organization is to structure life-goals so they are approach-based, concrete, imaginable and span a range of self-representations.

The main hypothesis about Evelyn’s vulnerability to depression was that her early family experiences limited the development of positive self-representations and associated life skills. When growing up, Evelyn endured several years of marital discord, conflict and miscommunication, with her parents unaware of its psychological impact on her. As time passed, Evelyn felt increasingly responsible for her family’s unhappiness, unable to solve her parents’ difficulties. She internalized a lot of unhappy memories and often felt helpless, unable to escape or improve the family situation. Her parents’ dissatisfaction with each other captured much of their attention, and Evelyn’s need for emotional support, encouragement and soothing was often overlooked.

This was compensated, to some degree, by her intelligence and aptitude at school where she was responsible, hard-working and successful, but her capacity to encourage herself and self-soothe was not consistently supported at home. On the contrary, the family atmosphere was characterized by criticism and harshness, which came to reflect Evelyn’s relationship with herself. Being responsible, intelligent and hard-working led to a successful path through school, university and her subsequent career, but her positive self-representations were few in number, narrowly invested in feeling responsible to others, particularly in her role as a managing director. This brought her a lot of career success and some periods of euthymic mood, but she had limited resilience to buffer negative interpersonal experiences when, as she perceived it, she made mistakes or let others down. As we have already observed, when her self-identity as a responsible managing director was disrupted Evelyn could switch rapidly into self-attack, self-blame and self-loathing.

Focusing on personal qualities was very challenging for Evelyn because she was very uncomfortable receiving positive feedback; it jarred as if it had no place within her. Throughout therapy, the therapist would comment on Evelyn’s good humour, compassion, intelligence and work expertise, in an attempt to strengthen her acceptance of these qualities, but this was limited by Evelyn’s reluctance to participate in this type of change. It is possible that Evelyn would have benefited from greater therapeutic focus on her memories, self-identity and life-goals, but throughout therapy she remained uncomfortable discussing herself, her early life in particular, and this limited the depth of self re-organization that was possible.

Risk reduction (4/42 sessions)

The aim of risk reduction is to reduce suicide risk when it is increased. Clients’ motives are explored in detail by asking about the intended and unintended consequences of suicidal actions. When feeling suicidal, clients’ attention often narrows around a specific need, for example, to be re-united with a loved one, to escape, to experience relief or put an end to a particular feeling. Evelyn’s mood rating did not enter the suicidal range (4/10 or less) during the course of SR-CBT, but there were occasions when she was bothered by suicidal thoughts, and on those occasions the therapy helped her to explore the goal of suicide: what did Evelyn imagine suicide would achieve? In Evelyn’s case, she believed it could result in ‘an end to hellish feelings’ and ‘not having to be me anymore’. This was tempered by potential unintended consequences, including pain, injury, illness and her husband being devastated. Evelyn recognized an inner battle between these pros and cons that she had lived with over several years.

The therapy tried to broaden Evelyn’s attention onto other life-goals and reasons for living, including seeing her company grow, supporting the development of key colleagues and enjoying holidays with her husband (Linehan et al ., Reference Linehan, Goodstein, Nielsen and Chiles 1983 ). Most importantly, it tried to identify non-lethal ways to respond to her felt-need to avoid ‘hellish’ emotions and escape herself. The main strategy was to encourage Evelyn to switch from avoidance to approach. Rather than avoid these feelings, she was encouraged to influence them so they occurred less frequently and respond to them differently when they were present. Rather than escape herself, she was encouraged to submit to a deeper acceptance of her personal qualities. Some of this therapeutic work was acutely uncomfortable for Evelyn, but it appeared to contribute to her increased safety over the course of the treatment.

Staying well (19/42 sessions)

Towards the end of the acute phase, four sessions of staying well were provided, aiming to consolidate the skills Evelyn had learned during therapy and apply them more independently (Jarrett et al ., Reference Jarrett, Kraft, Doyle, Foster, Eaves and Silver 2001 ). There remained an unpredictability in Evelyn’s moods that was frustrating and difficult for her to accept, and when her mood was more depressed (i.e. 6/10 or less) it was very difficult for her to remember and apply skills she had learned. It became apparent that this was a significant struggle for Evelyn, and this was what prompted the offer of maintenance therapy. This was initially expected to be monthly for 6 months, but it was extended to 15 months, reflecting the size of the task. There were two main aims: (a) to make Evelyn’s self-regulation skills more explicit and memorable; and (b) to help her access the skills when they were most needed, during depressed moods (i.e. 6/10 or less). Evelyn’s understanding of what she needed to do to stay well gradually became more explicit, and her skills became more automatic, but this was very slow learning that relied on multiple repetitions to become accessible during depressed moods.

Treatment outcomes

By the end of the acute SR-CBT phase, Evelyn’s PHQ-9 score had reduced from 19 to 2. This is a reliable change of more than 6 points that is also below the threshold for clinical caseness (McMillan et al ., Reference McMillan, Gilbody and Richards 2010 ). However, a pre–post comparison only takes account of two time-points and cannot capture the dynamics of mood patterns or changes within them. The daily mood ratings provided a richer description of those dynamics and also allowed comparisons between phases. The main questions were: (a) whether moods in the acute phase of SR-CBT were less depressed and more stable, compared with baseline; and (b) whether changes in mood during acute phase SR-CBT were sustained in the maintenance phase. Visual analysis of Fig.  1 confirms that there was a lot of variability within each phase, consistent with Evelyn’s formulation. A cyclical pattern was apparent, both within and across phases, with apparently milder depression and more stable mood during the SR-CBT phases (baseline median = 7; acute SR-CBT median = 8; maintenance SR-CBT median = 8). Evelyn’s risk was also less during SR-CBT: she scored 4 or less (indicating suicidal wishes) on 24/514 days during the baseline phase (4.6%) and 0/769 days during SR-CBT (0%).

Differences between phases were tested statistically using non-overlap methods (Morley, Reference Morley 2017 ; Parker and Vannest, Reference Parker, Vannest, Kratochwill and Levin 2014 ; Parker et al ., Reference Parker, Vannest, Davis and Sauber 2011 ). There was no significant trend within the baseline phase when Evelyn received standard CBT, ADM and CMHT (Tau-U=–0.028, Z=–0.963, p =0.336). The same underlying mood pattern was recurring without a significant trend towards better or worse mood, and this is reflected in the flat trend line in the baseline phase in Fig.  1 . There was therefore no need to control for baseline trend in the comparison with acute phase SR-CBT, which revealed a statistically significant improvement in mood, consistent with Fig.  1 (Tau-U=0.257, Z=6.167, p <0.001). Compared with baseline, Evelyn’s moods were significantly milder during acute SR-CBT, but there was also a significant decreasing trend during the acute phase which, without further intervention, could have led to relapse (Tau-U=–0.151, Z=–3.934, p <0.001). This is depicted in the sloping trend line in the acute phase in Fig.  1 . With this trend statistically controlled, there was a significant difference between acute phase SR-CBT and maintenance phase SR-CBT, favouring the maintenance phase (Tau-U=–0.093, Z=–2.192, p =0.028). Evelyn’s mood was more stable in the maintenance phase, with no significant trend for worsening or further improvement (Tau-U=–0.035, Z=–1.114, p =0.265). This is reflected in the flat trend line in the maintenance phase in Fig.  1 .

This single case demonstrates how SR-CBT is organized and delivered across a course of therapy. Because Evelyn kept a mood diary over an extended period, comparisons could be made between treatment phases. The case demonstrates the aim of SR-CBT: to provide effective therapy for difficult-to-treat clients who have received standard CBT in the past but where it has not had a beneficial or lasting effect (Barton and Armstrong, Reference Barton and Armstrong 2019 ). The pattern of results is consistent with the model’s claims, that SR-CBT can provide an effective alternative when standard CBT has not been sufficiently potent (Barton et al ., Reference Barton, Armstrong, Robinson and Bromley 2022 ). There are alternative explanations for the changes observed during SR-CBT, for example, that positive life events or other treatments were responsible for the effects. However, Evelyn attributed the changes to SR-CBT; there were no major positive life events during the 25 months of her treatment; she continued to take anti-depressant medication and receive CMHT support, but there were no substantial changes in medication and, due to her improvement, CMHT input was less than before.

Assuming that the changes are at least partly attributable to SR-CBT, this case does not provide evidence that SR-CBT is more effective than standard CBT; it does not address that question. The case is illustrative and not a comparative test: it is one case, without randomization or replication. A scientific comparison of cognitive therapy vs behavioural activation vs SR-CBT would need to balance the order in which they were received, since Evelyn’s gains during SR-CBT could be partly attributable to the preparatory effects of previous therapy. It would also need to match treatment doses and use a broader range of measures: 42 sessions is significantly greater than 15 sessions, which was the dose of the standard CBT she received in the baseline phase. Nevertheless, what can be claimed is that, in this particular case, high dose SR-CBT coincided with positive changes in mood that did not occur during standard CBT at a normal dose, and these changes were sustained over a 15-month maintenance phase. The enduring effect of SR-CBT in this case echoes the lasting benefits reported in an earlier version of this treatment (Barton et al ., Reference Barton, Armstrong, Freeston and Twaddle 2008 ).

Although a single case is limited without replication, single case methods have the potential to address issues in the field that are normally approached through randomized controlled trials and meta-analysis. For example, the bespoke combination of treatment components is open to empirical scrutiny to find out how much variance occurs across cases, and whether the same or different ingredients are associated with better outcomes. If it is the same ingredients, SR-CBT could become more protocolized in the future; if it is different ingredients, there is a case for continued individualization with this client group. Repeated measure designs also have the potential to detect trends that are not usually measured in RCTs, the best example in this study being the decreasing trend in the acute SR-CBT phase, even though this phase had significantly milder depression than the baseline. If this pattern was replicated in other cases, it could be a way of detecting empirically which cases are at greater risk of relapse through their response to acute phase treatment.

Two further questions need to be addressed. Firstly, how similar or different is SR-CBT compared with standard CBT? Therapists use core CBT skills to provide SR-CBT and it certainly has overlaps with other CBT treatments, for example, mental freedom shares features with rumination-focused CBT (Watkins and Roberts, Reference Watkins and Roberts 2020 ), and active engagement shares features with behavioural activation (Martell et al ., Reference Martell, Addis and Jacobsen 2001 ; Martell et al ., Reference Martell, Dimidjian and Herman-Dunn 2010 ) and activity scheduling in cognitive therapy (Beck et al ., Reference Beck, Rush, Shaw and Emery 1979 ). Readers are encouraged to access the concurrent article that explores these similarities and differences in more detail (Barton et al ., Reference Barton, Armstrong, Robinson and Bromley 2022 ).

Secondly, are the effects of SR-CBT attributable to high dose treatment rather than specific treatment components? This possibility cannot be ruled out, but the change pattern depicted in Fig.  1 suggests a specific response to SR-CBT, rather than a simple dose effect. However, this question needs to be addressed through replication in further studies, and the health economics of high dose treatment also need consideration. Arguably, an effective high dose treatment for difficult-to-treat cases would save resources in the long term, given the healthcare costs incurred by treatment-resistant depression (Johnston et al ., Reference Johnston, Powell, Anderson, Szabo and Cline 2019 ). For some clients, fast learning is not possible and slow learning across a high intensity treatment may be more cost-effective than subsequent multiple brief episodes of care. For example, slower change is inevitable when working with non-verbal aspects of trauma, and this may be one of the reasons why treatment responses in chronic depression are superior for doses of 30 sessions or greater (Brewin et al ., Reference Brewin, Reynolds and Tata 1999 ; Cuijpers et al ., Reference Cuijpers, van Straten, Schuurmans, van Oppen, Hollon and Andersson 2009 ). With respect to the current case, consider the costs incurred by Evelyn’s treatment in the 13 years prior to receiving SR-CBT, and the potential savings in the years ahead, if her treatment gains are sustained. The efficacy of SR-CBT and its health economics are now undergoing further empirical tests.

(a) When possible, increase the treatment dose compared with standard CBT.

(b) Pay more attention to building the working alliance by overcoming alliance barriers.

(c) Pay more attention to less-depressed moods as a way of finding a path out of depression.

(d) Conduct behavioural experiments that seek to influence clients’ preferences, rather than disconfirm their negative predictions.

(2) Therapists should consider using individualized measures, such as daily mood ratings, alongside standard measures as a way of observing trends and patterns of change.

Copies of the single case dataset are available from the first author on request.

Acknowledgements

The authors would like to thank colleagues who provided feedback on drafts and contributed to the development of the treatment components: Nina Brauner, Beth Bromley, Elisabeth Felter, Dave Haggarty, Youngsuk Kim, Lucy Robinson and Karl Taylor.

Stephen Barton: Conceptualization (lead), Data curation (lead), Formal analysis (lead), Investigation (lead), Methodology (lead), Project administration (lead), Writing – original draft (lead), Writing – review & editing (lead); Peter Armstrong: Conceptualization (supporting), Investigation (supporting), Supervision (lead); Stephen Holland: Conceptualization (supporting), Project administration (supporting), Writing – original draft (supporting), Writing – review & editing (supporting); Hayley Tyson-Adams: Conceptualization (supporting), Project administration (supporting), Writing – original draft (supporting), Writing – review & editing (supporting).

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The authors have no competing interests to declare.

The authors have abided by the ethical principles and code of conduct set out by the British Association of Behavioural and Cognitive Psychotherapies and British Psychological Society. The reported study is practice-based evidence and did not receive ethical approval in advance. In lieu of this, oversight was sought from CNTW Foundation Trust management which supported service-user involvement in collecting practice-based evidence. The service user was an active participant in the research process, read the manuscript and agreed to it going forward for publication.

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• Stephen B. Barton (a1) (a2) , Peter V. Armstrong (a1) , Stephen Holland (a1) and Hayley Tyson-Adams (a3)
• DOI: https://doi.org/10.1017/S1754470X22000319

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4 Treatment of Depression

• Published: February 2013
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Chapter 4 covers the treatment of depression, and discusses popular myths regarding depression, its frequency, characteristics and diagnosis, and includes case studies, assessment, case conceptualization, intervention development and course of treatment, problems that may arise in therapy, ethical considerations, common mistakes in the course of treatment, relapse prevention, and cultural factors.

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5 Reasons Why Depression Looks Different in Everyone

No two people have the exact same depression. what explains these differences.

Posted September 21, 2024 | Reviewed by Abigail Fagan

• What Is Depression?
• Take our Depression Test
• Find a therapist to overcome depression
• Depression affects 280 million people, but it looks different in everyone.
• How we define depression plays a huge role.
• Age, sex, and cultural differences also play a role.

Globally, over 280 million people have depression . But if you were to ask a random sample of 1,000 people to describe their depression , you would have a low chance of finding two people who have the exact same experience.

Why is that?

Defining Depression

We first need to define depression to understand why it looks different in everyone. Depression, or a Major Depressive Episode, is a mental health diagnosis that is characterized by nine symptoms: (1) depressed mood; (2) “ anhedonia ,” or markedly diminished interest or pleasure; (3) increase or decrease in either weight or appetite ; (4) insomnia or hypersomnia; (5) psychomotor agitation or retardation; (6) fatigue or loss of energy; (7) feelings of worthlessness or inappropriate guilt ; (8) diminished ability to think or concentrate, or indecisiveness; and (9) recurrent thoughts of death or recurrent suicidal ideation ( American Psychiatric Association, 2022 ).

A diagnosis requires that someone has at least five of these symptoms, one of which must be either depressed mood or anhedonia. These symptoms need to be persistent for at least two weeks and cause significant distress or impairment. Additionally, these symptoms should not be better explained by another factor, like a new medication .

So, if we have these defined criteria, why does depression vary so much from person to person?

1. The criteria are not one-size-fits-all. The definition of depression, itself, invites differences from person to person. Research shows that it is rare that any two individuals will have the exact same combination of symptoms—as you can see in the criteria above, depression is defined by a combination of five out of nine symptoms. One study, led by Eiko Fried and Randolph Nesse (2015), analyzed over 3,000 patients and investigated how often patients share the same symptom experience. Their study revealed that how we define depression can result in over 1,030 unique symptom profiles! The most common symptom profile was only endorsed by 1.8% of the sample. Put simply, there are many, many ways to meet the criteria for depression.

2. Depression is defined by subjective experiences. Depression is a diagnosis that is rooted in subjective experiences like mood, emotions, thoughts, and behaviors. The word “subjective” does not mean someone’s experience is not real—if someone feels sad, then they feel sad. But as a psychologist, I cannot give someone a blood test to assess if they are “happy” or “sad,” nor can I use a brain scan to assess for suicidal thoughts. Even for the physical symptoms, like loss of energy, there is no reliable objective test to determine the severity of someone’s fatigue. To diagnose depression, clinicians must conduct interviews with patients to assess how they feel. And, as we all know, one person’s “sad” looks a lot different than another person’s “sad.”

3. Depression presents differently across age groups. How depression looks can vary across children, teenagers , and adults. Research shows that specific symptoms may show up more frequently in certain age groups. In one study by Rice and colleagues (2019), they analyzed how frequently depression symptoms were endorsed by adolescents and adults. Their study found that “vegetative symptoms”—like appetite and weight change, loss of energy, and insomnia—were more commonly seen in adolescent depression than adult depression. Meanwhile, adult depression was more likely to include symptoms of anhedonia and concentration problems. These findings can help people become more sensitive to noticing signs of depression based on age.

4. Sex differences exist between men and women. Large global studies have consistently found that women are more likely to be diagnosed with depression than men. Among adults in the United States , 10.3% of women—compared to 6.2% of men—met criteria for depression in 2021 (NIMH, 2023). The reasons for these sex differences are complex, driven by an interplay of social, psychological, and biological factors ( Eid et al., 2019 ). It is also possible that how we define depression makes it easier for women to meet the criteria, and men may present with depression differently ( Martin et al., 2013 ). In support of this idea, Cavanagh and colleagues (2017) conducted a large review of studies and found that men with depression were more likely to have difficulties with alcohol use, drug use, and risk-taking /poor impulse control behaviors. Meanwhile, women had a higher frequency and severity of traditional depression criteria, like depressed mood, appetite/weight changes, and sleep difficulties. Recognizing these differences can help both men and women get help for depression.

5. Cultural differences are real, but more research is needed to understand these differences. Cross-cultural research shows that the expression of positive and negative emotions can vary across countries and cultures. This is important to note because depression—a diagnosis characterized by mood and emotions—is mostly defined from a Westernized perspective. The criteria were not developed and tested in other countries, and thus our estimates of depression around the world may be somewhat biased. For example, a multinational analysis of 116 countries found that countries meaningfully varied in their expression and valuing of emotions ( Tay et al., 2011 ). While the range of emotions if felt universally across cultures, some cultures are more likely to express joy than others, and the same rule of thumb applies for negative emotions ( Cordaro et al., 2018 ). However, a new study by Panaite and Cohen (2024) found some consistency across countries in terms of how emotions were reported among adults with depression, compared to adults without depression. Their study highlighted the need for more cross-cultural research to understand the complexities of how depression is experienced across the world.

The Takeaway

There is no “one” look to depression. Depression does not have one mascot that represents everyone’s experience. However, by understanding why depression varies from person to person, we are better positioned to provide one-fits-one care and support from person to person.

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Cordaro, D. T., Sun, R., Keltner, D., Kamble, S., Huddar, N., & McNeil, G. (2018). Universals and cultural variations in 22 emotional expressions across five cultures. Emotion , 18 (1), 75.

Eid, R. S., Gobinath, A. R., & Galea, L. A. (2019). Sex differences in depression: Insights from clinical and preclinical studies. Progress in Neurobiology , 176 , 86-102.

Fried, E. I., & Nesse, R. M. (2015). Depression is not a consistent syndrome: An investigation of unique symptom patterns in the STAR* D study. Journal of Affective Disorders , 172 , 96-102.

Haroz, E. E., Ritchey, M., Bass, J. K., Kohrt, B. A., Augustinavicius, J., Michalopoulos, L., ... & Bolton, P. (2017). How is depression experienced around the world? A systematic review of qualitative literature. Social Science & Medicine , 183 , 151-162.

National Institute of Mental Health (NIMH). (2023). Major Depression . https://www.nimh.nih.gov/health/statistics/major-depression

Panaite, V., & Cohen, N. (2023). Does Major Depression Differentially Affect Daily Affect in Adults From Six Middle-Income Countries: China, Ghana, India, Mexico, Russian Federation, and South Africa?. Clinical Psychological Science , 21677026231194601.

Rice, F., Riglin, L., Lomax, T., Souter, E., Potter, R., Smith, D. J., ... & Thapar, A. (2019). Adolescent and adult differences in major depression symptom profiles. Journal of Affective Disorders , 243 , 175-181.

Tay, L., Diener, E., Drasgow, F., & Vermunt, J. K. (2011). Multilevel mixed-measurement IRT analysis: An explication and application to self-reported emotions across the world. Organizational Research Methods , 14 (1), 177-207.

Andrew Devendorf, Ph.D., is a clinical psychologist and Postdoctoral Research Fellow at the Seattle Puget Sound VA.

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• Malays Fam Physician
• v.17(1); 2022 Mar 28

Case scenario: Management of major depressive disorder in primary care based on the updated Malaysian clinical practice guidelines

Uma visvalingam.

MBBS (MAHE), Master of Medicine (Psychiatry) (UKM), Department of Psychiatry and Mental Health, Hospital Putrajaya, Putrajaya, Malaysia

Umi Adzlin Silim

MD (UKM), M. Med (Psychiatry) (UKM), Department of Psychiatry and Mental Health, Hospital Serdang, Serdang, Selangor, Malaysia

Ahmad Zahari Muhammad Muhsin

MB., BCh., BAO (UCD, Ireland), M. Psych Med (Malaya), Department of Psychological Medicine, Faculty of Medicine Universiti Malaya, Kuala Lumpur, Malaysia

Firdaus Abdul Gani

MBBS (Malaya) M.Med (Psy) (USM) CMIA (NIOSH), Department of Psychiatry and Mental Health, Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang, Malaysia

Noormazita Mislan

MB, BCh, BAO (Ireland), M Med. (Psychiatry) (UKM), Department of Psychiatry and Mental Health, Hospital Tuanku Ja'afar, Seremban, Negeri Sembilan, Malaysia

Noor Izuana Redzuan

MBBS (Malaya), Dr in Psychiatry (UKM), Department of Psychiatry and Mental Health, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

Peter Kuan Hoe Low

MB, BCh, BAO (Ireland), M.Psych Med (UM), Department of Psychiatry and Mental Health, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

Sing Yee Tan

MBBS (Malaya), M.Med (Family Med) (UM), Klinik Kesihatan Jenjarom, Jenjarom Selangor, Malaysia

Masseni Abd Aziz

MD (USM) M Med (Fammed) USM, Klinik Kesihatan Umbai, Merlimau, Melaka, Malaysia

Aida Syarinaz Ahmad Adlan

MBBS (Malaya), M. Psych Med (UM), PostGrad. Dip. (Dynamic Psychotherapy) (Mcgill University), Department of Psychological Medicine, Faculty of Medicine, Universiti Malaya Kuala, Lumpur, Malaysia

Suzaily Wahab

MD (UKM), MMed Psych (UKM), Hospital Canselor Tuanku Muhriz UKM, Kuala Lumpur, Malaysia

Aida Farhana Suhaimi

B. Psych (Adelaide), M. Psych (Clin. Psych) (Tasmania), PhD (Psychological Medicine) (UPM), Department of Psychiatry and Mental Health, Hospital Putrajaya, Putrajaya, Malaysia

Nurul Syakilah Embok Raub

BPharm (Hons) (CUCMS), MPH (Malaya), Pharmacy Enforcement Branch, Selangor Health State Department, Shah Alam, Selangor, Malaysia

Siti Mariam Mohtar

BPharm (UniSA), Malaysian Health Technology Assessment Section (MaHTAS), Ministry of Health Malaysia, Putrajaya, Malaysia

Mohd Aminuddin Mohd Yusof

MD (UKM), MPH (Epidemiology) (Malaya), Malaysian Health Technology Assessment Section (MaHTAS), Ministry of Health Malaysia, Putrajaya, Malaysia, Email: moc.oohay@rd2ma

Major depressive disorder (MDD) is a common but complex illness that is frequently presented in the primary care setting. Managing this disorder in primary care can be difficult, and many patients are underdiagnosed and/or undertreated. The Malaysian Clinical Practice Guidelines (CPG) on the Management of Major Depressive Disorder (MDD) (2nd ed.), published in 2019, covers screening, diagnosis, treatment and referral (which frequently pose a challenge in the primary care setting) while minimising variation in clinical practice.

Introduction

MDD is one of the most common mental illnesses encountered in primary care. It presents with a combination of symptoms that may complicate its management.

This mental disorder requires specific treatment approaches and is projected to be the leading cause of the disease burden in 2030. 1 Patients experiencing this ailment are at elevated risk for early mortality from physical disorders and suicide. 2 In Malaysia in particular, MDD contributes to 6.9% of total Years Living with Disability. 3

Ensuring full functional recovery and prevention of relapse makes remission the targeted outcome for treatment of MDD. In contrast, nonremission of depressive symptoms in MDD can impact functionality 4 and subsequently amplify the economic burden that the illness imposes.

About the new edition

The highlights of the updated CPG MDD (2nd ed.) are as follows:

• emphasis on psychosocial and psychological interventions, particularly for mild to moderate MDD
• inclusion of all second-generation antidepressants as the first-line pharmacotherapy
• introduction of new emerging treatments, ie. intravenous ketamine for acute phase and intranasal esketamine for next-step treatment/treatment-resistant MDD
• improvement in pre-treatment screening and monitoring of treatment
• integration of mental health into other health services with emphasis on collaborative care
• addition of 2 new chapters on special populations (pregnancy and postpartum, chronic medical illness) and table on safety profile of pharmacotherapy in pregnancy and breastfeeding
• comprehensive, holistic biopsychosocial-spiritual approaches addressing psychospirituality

Details of the evidence supporting the above statements can be found in Clinical Practice Guidelines on the Management of Major Depressive Disorder (2nd ed.) 2019, available on the following websites: http://www.moh.gov.my (Ministry of Health Malaysia) and http://www.acadmed.org.my (Academy of Medicine). Corresponding organisation: CPG Secretariat, Health Technology Assessment Section, Medical Development Division, Ministry of Health Malaysia; contactable at ym.vog.hom@aisyalamath .

Statement of intent

This is a support tool for implementation of CPG Management of Major Depressive Disorder (2nd ed.).

Healthcare providers are advised of their responsibility to implement this evidence-based CPG in their local context. Such implementation will lead to capacity building to ensure better accessibility of psychosocial and psychological services. More options in pharmacotherapy facilitate flexibility in prescribing antidepressants among clinicians. Further integration of mental health into other health services, upscaling of mental health service development in perinatal and medical services, and enhancement of collaborative care will incorporate holistic approaches into care.

Case Scenario

Tini is a female college student aged 24 years old. She comes to the health clinic accompanied by a friend and complains of several symptoms that she has experienced over the past 4 weeks. She reports:

• difficulty falling asleep, feeling tired after waking up in the morning and experiencing headaches
• difficulty staying focused during classes. These symptoms have led to deterioration in her study and prompted her to seek advice from the doctor.

Will you screen her for depression?

Yes, because the patient presents with multiple vague symptoms and sleep disturbance. 5 (Refer to Subchapter 2.1, page 3 in CPG.)

What tools are used to screen for depression?

Screening tools for depression are:

• Beck Depression Inventory (BDI)
• Depression Anxiety and Stress Scale (DASS)
• Patient Health Questionnaire-9 (PHQ-9)
• Hospital Anxiety and Depression Scale (HADS)
• Whooley Questions

Screening for depression using Whooley Questions in primary care may be considered in people at risk. 5

( Refer to Subchapter 2.1, pages 3 and 4 in CPG. )

• “During the past month, have you often been bothered by feeling down, depressed or hopeless?”
• “During the past month, have you often been bothered by having little interest or pleasure in doing things?

The doctor decides to use Whooley Questions, and Tini answers “yes” to both questions.

How would you proceed from here to further assess for depression?

Assessment of depression consists of:

• detailed history taking (Refer to Subchapter 2.2, page 4 in CPG.)
• mental state examination (MSE), including evaluation of symptom severity, presence of psychotic symptoms and risk of harm to self and others
• physical examination to rule out organic causes
• investigations where indicated — biological and psychosocial investigations

Upon further assessment, Tini reveals that she feels overwhelmingly sad. She is frequently tearful and reports feeling excessively guilty, blaming herself for not performing well enough in her studies. Her postings on social media have been revolving around themes of self-defeat. Despite feeling low, she still strives to attend classes and complete her assignments. However, her academic performance has exhibited a marked deterioration. There is no history to suggest hypomanic, manic or psychotic symptoms. She denies using any illicit substances or alcohol. Her menstrual cycle is normal and does not correspond to her mood changes.

MSE reveals a young lady who appears to be in distress. Rapport is easily established, but her eyes are downcast. Her speech is relevant, with low tone. She describes her mood as sad; she is tearful while talking about her poor results, with appropriate affect. She harbours multiple unhelpful thoughts, eg. “I’m a failure” and “I’m useless”. She exhibits no suicidal ideations, delusions or hallucinations. Her concentration is poor, and insight is partial.

Physical examination reveals no recent selfharm scars, and examination of other systems is unremarkable. Biological investigations such as full blood count and thyroid function test are within normal range. Corroborative history is taken from accompanying person to verify the symptoms.

How would you arrive at the diagnosis and severity?

Diagnosis of depression can be made using the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or the 10th revision of the International Statistical Classification of Disease and Related Health Problems (ICD-10). 5 (Refer to Appendix 3 and 4, pages 73-76 in CPG.) 6 , 7

In the last 2 weeks, Tini has been experiencing:

• poor concentration
• excessive guilt

These symptoms have caused marked impairment in her academic functioning. Thus, she is diagnosed as having MDD with mild to moderate severity in acute phase and can be treated in primary care.

Severity according to DSM-5

• Five or more symptoms are present, which cause distress but are manageable
• Result in minor impairment in social or occupational functioning
• Symptom presentation and functional impairment between 2 severities
• Most of the symptoms are present with marked impairment in functioning

What can be offered to this patient?

Psychosocial interventions and psychotherapy with or without pharmacotherapy. 5 (Refer to Algorithm 1. Treatment of Major Depressive Disorder, page xii in CPG)

ALGORITHM 1. TREATMENT OF MAJOR DEPRESSIVE DISORDER

Psychosocial interventions include the following:

• symptoms and course of depression
• biopsychosocial model of aetiology
• pharmacotherapy for acute phase and maintenance
• drug side effects and complications
• importance of medication adherence
• early signs of recurrence
• management of relapse and recurrence
• counselling/non-directive supportive therapy - aims to guide the person in decision-making and allow to ventilate their emotions
• relaxation - a method to help a person attain a state of calmness, eg. breathing exercise, progressive muscle relaxation, relaxation imagery
• peer intervention - eg. peer support group
• exercise - activity of 45-60 minutes per session, up to 3 times per week, and prescribed for 10-12 weeks

(Refer to subchapter 4.1.1, pages 9-12 in CPG.)

However, the doctor may choose to start antidepressant medication as an initial measure in some situations, for example:

• past history of moderate to severe depression
• patient’s preference
• previous response to antidepressants
• lack of response to non-pharmacotherapy interventions

What are the types of psychotherapy that can be offered in mild to moderate MDD, and what factors should be considered before starting psychotherapy?

Psychotherapy for the treatment of MDD has been shown to reduce psychological distress and improve recovery through the therapeutic relationship between the therapist and the patient.

In mild to moderate MDD, psychosocial intervention and psychotherapy should be offered, based on resource availability, and may include but are not restricted to the following 5 :

• Cognitive behavioural therapy (CBT)
• Interpersonal therapy
• Problem-solving therapy
• Behavioural therapy
• Internet-based CBT

The type of psychotherapy offered to the patient will depend on various factors, including 5 :

• patient preference and attitude
• nature of depression
• availability of trained therapist
• therapeutic alliance
• availability of therapy

(Refer to Subchapter 4.1.1, page 17 in CPG.)

After shared-decision making, Tini receives psychosocial intervention, that includes:

• psychoeducation
• non-directive supportive therapy
• lifestyle modification, e.g. restoring healthy sleep hygiene and adopting healthy eating habits
• relaxation, e.g. progressive muscle relaxation, imagery and breathing technique

Tini will benefit from CBT due to her multiple unhelpful thoughts, for example, “I’m a failure” and “I’m useless”.

CBT helps improve understanding of the impact of a person’s unhelpful thoughts on current behaviour and functioning through cognitive restructuring and a behavioural approach. By learning to correctly identify these negative thinking patterns, Tini can then challenge such thoughts repeatedly to replace disordered thinking with more rational, balanced and healthy thinking. However, she is not able to commit to regular sessions of CBT due to a demanding academic schedule and upcoming final examination. After further discussion, Tini opts for pharmacotherapy.

What are the options for pharmacotherapy?

The choice of antidepressant medication will depend on various factors, including efficacy and tolerability, patient profile and comorbidities, concomitant medications and drug-drug interactions, cost and availability, as well as the patient’s preference. Taking into account efficacy and side effect profiles, most second-generation antidepressants, namely selective serotonin reuptake inhibitors (SSRIs), serotonin noradrenaline reuptake inhibitors (SNRIs), noradrenergic and specific serotonergic antidepressants (NaSSAs), melatonergic agonist and serotonergic antagonist, noradrenaline/dopamine-reuptake inhibitors (NDRIs) and a multimodal antidepressants may be considered as the initial treatment medication, while the older antidepressants such as tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may be subsequently considered for a later choice. 5 (Refer to Subchapter 4.1.2, page 18 in CPG.)

Since Tini is being seen at a health clinic, the widely available SSRIs are sertraline and fluvoxamine. Sertraline has fewer gastrointestinal side effects and drug interactions compared with fluvoxamine. TCAs are not the treatment of choice due to prominent side effects. Tini is put on tablet sertraline 50 mg daily and educated on the anticipated onset of response and possible side effects. Short-term and low dose benzodiazepine, eg. alprazolam or lorazepam, may be offered as an adjunct to treat her insomnia. (Refer to Subchapter 4.1.2, page 24 in CPG.) Tini is given tablet lorazepam 0.5 mg at night for 2 weeks. She is asked to come in for a follow-up.

What is her follow-up and monitoring plan?

The following should be done:

(Refer to Appendix 8, page 81 in CPG.)

• Titrate up by 50 mg within 1-2 weeks (but may be done earlier based on clinical judgement)
• Monitor biological parameters if indicated (Refer to Table 5. Ongoing monitoring during treatment of MDD, page 57 in CPG.)

During follow-up at 2 weeks, she is noted to show partial response despite being compliant with good tolerability. She is not experienceing nausea, diarrhoea, headache, constipation, dry mouth or somnolence. She reports being less tearful. Her sleep and ability to focus have improved. Tini has started engaging in regular exercise and practises relaxation, especially before sleep. Tablet sertraline is optimised to 100 mg daily, while tablet lorazepam is reduced to 0.5 mg PRN.

Tini is reviewed again within 4 weeks; during this subsequent follow-up, she achieves full remission. Tablet lorazepam is stopped. She is then advised to continue tablet sertraline for at least 6-9 months in maintenance phase. The aim in this phase is to prevent relapse and recurrence of MDD. In view of her young age, no comorbidities and good tolerability, repeated electrolyte monitoring is not indicated.

(Refer to Algorithm 2. Pharmacotherapy for Major Depressive Disorder, page xiii in CPG.)

ALGORITHM 2. PHARMACOTHERAPY FOR MAJOR DEPRESSIVE DISORDER

• Bipolar Disorder
• Therapy Center
• When To See a Therapist
• Types of Therapy
• Best Online Therapy
• Best Couples Therapy
• Managing Stress
• Sleep and Dreaming
• Understanding Emotions
• Self-Improvement
• Healthy Relationships
• Student Resources
• Personality Types
• Sweepstakes
• Guided Meditations
• Verywell Mind Insights
• 2024 Verywell Mind 25
• Mental Health in the Classroom
• Editorial Process
• Meet Our Review Board
• Crisis Support

What Is a Case Study?

Weighing the pros and cons of this method of research

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."