The Girl Who Is 'Only Exam-Stressed'
Anita, 17, is a Class XII student in a district town. After failing two unit tests in October she has been low for about six weeks. Her mother reports that she sleeps four to five hours, wakes at 3 a.m., has stopped eating lunch, cries after school and has lost interest in the state-level debate competition she had qualified for. She still attends school, bathes daily and finishes homework, though slowly. She says, 'I am useless; I will fail everything.' She has missed two hockey practices but no examinations, and her class teacher says she has become irritable when asked about results. There is no history of manic episodes, no alcohol or drug use and no head injury. Her father was treated for depression at 40. Her haemoglobin is 8.2 g/dL. The school doctor calls her 'just exam-stressed'. Her parents ask you, the school psychologist, whether she has a mental disorder or is simply sad.
1. Anita's parents want a yes-or-no answer. Decide whether her presentation meets the threshold for a major depressive episode, showing which criteria are and are not satisfied, and state what you must ask before you answer at all.
Read the worked answer
Framework used: a major depressive episode needs at least five of nine symptoms, nearly every day for at least two weeks, with at least one being depressed mood or loss of interest, and clinically significant distress or impairment, not due to a substance or medical condition, and not part of a bipolar episode.
Mapping the evidence, not just naming criteria:
- Depressed mood: six weeks, described by mother and teacher (irritability in adolescents counts as mood change).
- Loss of interest: dropped the debate competition she had qualified for.
- Sleep: 4–5 hours with 3 a.m. waking (early-morning awakening is more typical of depressive illness than of ordinary exam worry).
- Appetite: stopped eating lunch.
- Worthlessness: 'I am useless.'
- Concentration: homework finished only slowly (probable sixth symptom).
Five symptoms are clearly present, so the symptom-count threshold is crossed. Duration (six weeks) exceeds two weeks. Impairment of role functioning is only partial - she still attends school - but the criterion is significant distress or impairment, and the distress is marked. So the answer is: provisionally yes, she meets threshold, and the school doctor's 'just exam-stressed' label stops enquiry too early.
What must be asked before finalising: suicidal ideation, plan and access to means (ask today, never later); any past elevated-mood episode (to exclude bipolarity, which changes treatment); psychotic symptoms; fatigue and thyroid symptoms; recent bereavement or other loss; previous episodes; a teacher's structured report.
Why not 'simply sad': ordinary sadness is proportionate to the setback, does not usually produce early-morning waking, global self-condemnation and appetite loss, and lifts when the situation changes.
2. The school doctor wants to record 'exam stress - no action'. Give the reasoning you would use to argue for a different plan, covering the haemoglobin value and the family history.
Read the worked answer
1. The low haemoglobin must be explained before the picture is read as purely psychological. Anaemia (8.2 g/dL) produces fatigue, poor concentration, low energy and disturbed sleep - symptoms that overlap heavily with depression. It must be corrected and reviewed, not ignored. The causal arrow can also run the other way: reduced eating lowers intake and worsens anaemia. Two-way causality is the honest formulation.
2. Family history shifts probability, not diagnosis. A first-degree relative with depression raises risk (moderate heritability, roughly 30–40% in twin studies) and argues for closer monitoring, earlier treatment and relapse prevention. It cannot by itself make the diagnosis.
3. 'No action' is the wrong default even if the diagnosis is uncertain. A provisional formulation with a two-week review is safer than a closed file, because the risk that matters - suicidality - is not assessed by a haemoglobin report.
4. Plan: safety assessment; physician referral for anaemia; brief structured assessment plus psychoeducation with Anita; sleep and study-load review; parental session with Anita's consent; review in two weeks; clear referral route to a psychiatrist if severity increases.
5. Ethics of the record: a school health note is confidential. Record a clinical description, share the minimum necessary with teachers, and do not write a diagnostic label a 17-year-old will carry into future applications without her consent.
3. Distinguish Anita's picture from (i) persistent depressive disorder and (ii) an adjustment disorder, and explain how the distinction would change what you actually do in the next month.
Read the worked answer
(i) Persistent depressive disorder requires depressed mood for most of the day, more days than not, for at least two years in adults (one year in children and adolescents), plus additional symptoms. Six weeks cannot satisfy it. A six-week history with clear symptom counting therefore points to a depressive episode, not a chronic low-grade mood disorder - though if the history were in fact two years long, the label and the treatment length would both change.
(ii) Adjustment disorder requires symptoms beginning within three months of an identifiable stressor (here, failing two unit tests) - which fits the timing. But it is a residual category: it is not given when the full criteria for another disorder are met. Since Anita appears to meet criteria for a depressive episode, the depressive episode takes precedence; calling it adjustment disorder would under-treat her.
Why the distinction is practical, not academic:
- If adjustment reaction: brief supportive counselling, problem-solving around study method, anticipated natural recovery in weeks, no medication discussion.
- If depressive episode: structured psychotherapy (CBT or interpersonal therapy) as first line, active monitoring of suicide risk, consideration of medication only if moderate-to-severe or unresponsive, and planning for relapse prevention and follow-up beyond the examinations.
- If persistent depressive disorder: longer treatment horizon and a different conversation with the family about chronicity.
So the next month's actions - frequency of contact, who is involved, whether a psychiatric opinion is sought - follow directly from which of these three formulations you write down.