Editor’s note: Recently, CCPR presented the following hypothetical case to leading child and adolescent development authority Calvin Colarusso, MD, for his advice on how to help a young man presenting with a possible major depressive disorder (MDD).

The case: As he struggles to complete his senior college research project, a 23-year-old majoring in chemistry has a recurrence of severe depressive symptoms. He talks of his uncertainty about what he will do after graduating. He is overcome by worry about whether he can find a job, and whether he should apply to graduate school or wait. He is unable to concentrate in class, and he is having significant trouble eating and sleeping. He has no acute intent to harm himself, but at times he feels that, if he is unable to make good on his expensive education, life won’t be worth living. The patient has had 3 similar episodes in the past. When he was thinking about college, one occurred during high school. As he was adjusting to being away from home, another happened in the fall of his freshman year. Another episode occurred a year ago just after finishing a semester abroad and leaving new friends and experiences.

Dr. Colarusso: What are the highlights of his earlier life?
CCPR: His history is notable for good grades, usual types of friends and activities, and very close relationships to both parents. His mother was a successful business professional, who then stayed home with the children. The father is an engineer, whose company over the past several years has had significant ups and downs. The patient tended to avoid teen parties and dating. He worked in a grocery store during high school and played varsity basketball and baseball. Medical history is positive for a couple of minor concussions sustained in sports with no clear residual symptoms, although one was temporally related to the first significant depression episode in high school. There is an older brother, who has learning challenges, and a younger sister with good function.

Dr. Colarusso: How has the patient been doing recently?
CCPR: He’s been doing pretty well. His grades are quite good. He sees a counselor at school once or twice per semester to monitor his overall function, which is what the school offers as part of tuition. The patient says he finds this helpful.

Dr. Colarusso: What about friends and dating?
CCPR: He has friends and is socially active, but he prioritizes his school work: He typically goes out 1–3 times per week, depending on how heavy his workload is. He uses alcohol roughly 2–3 times per week, consuming an average of 3 beers each time. He also smokes marijuana about once a week “to relax”; however, he does not like the added suspiciousness that the drug creates when he uses it. He says that he has seen several girls over the course of his high school and college career, but he is not dating seriously, and this is not a current focus for him.
Dr. Colarusso: It’s pretty clear that he has depression, and he would very likely meet criteria for a DSM-5 diagnosis of major depressive disorder with anxious features. But going beyond the surface diagnosis, there are clues in his developmental history that beg for more information. 

CCPR: What other things should we be asking about?
Dr. Colarusso: Invest some time in taking a more detailed social and sexual history. Look closely at the quality of his relationships with his parents, his siblings, and his peers. Ask about how he did in school early on, and whether he had trouble separating from his parents. Also, his lack of interest in dating may be an important piece here. Be sure to ask more about why he hasn’t wanted to date, about his attraction or not to women and men, and his family attitudes toward dating and sexuality.

CCPR: What developmental aspects are at play here?
Dr. Colarusso: Although 23 years old, he is dealing with the adolescent developmental task of separation from his mother and father and establishing that comfortable sense of autonomy associated with developmental transitions, such as leaving home for college and then leaving college for the work world. He’s having trouble managing these things with less stress and without a depressive response. It is possible that separation issues—such as going to kindergarten or going away to camp—played a role in his early development.

CCPR: How so?
Dr. Colarusso: Entering the adult work world after years of education and dependence is a daunting task for many. He may be affected by patterns of thinking and emotional reactions that he developed early on and has carried with him over the years. In particular, my guess is that he may be having trouble living up to the expectations of his successful parents and at least one of his siblings. This can be intimidating and make the transition more difficult.

CCPR: Where do relationship dynamics impact the presentation of this patient as well as our understanding of his predicament?
Dr. Colarusso: Although there is very little information to go on, he also seems to be struggling with the adolescent and young adult task of establishing a comfortable sexual life. I say this because this is the age when most young adults have a very heightened sexual drive. Even when he’s had more freedom from parental oversight, this patient seems to have been less engaged in this fundamental aspect of development for several years. To dampen his anxiety, he appears to be using alcohol and marijuana. If you are pressed for time and focused mainly on medication assessment, It’s the kind of thing that you might overlook. But it would be unfortunate to miss addressing such an issue that could easily be driving the depression.

CCPR: How do these perspectives apply in a practical way to treatment?
Dr. Colarusso: It’s very common for younger adults (ages 20–40) to have these kinds of unresolved adolescent developmental tasks. Aside from using medication for depression, if needed, I would approach therapy by asking the patient if he notices an inner conflict between wanting to be on his own and fearing the idea of being on his own. From there, ask him about past experiences that felt similar and had similar themes, perhaps when sleeping away at camp or a friend’s home. Do not be surprised when other themes become clear as well, such as sexual feelings. Meanwhile, be attuned to any transference that arises in the therapy sessions. You might find that the patient’s manner and communication with the therapist have similarities to the present and past challenges. Once these are all openly talked about, the patient has a more conscious ability to problem-solve and choose how to move forward. This is a simplified summary of how dynamic approaches to therapy unfold; however, most psychiatrists should be familiar with these ideas as they put the patient’s symptoms into the context of lifelong development.

CCPR: Thank you for your time, Dr. Colarusso.