Seven Weeks of 'Just Stress'
A 28-year-old school teacher, Sunita, comes to the counsellor after a colleague insists. For seven weeks she has felt low and tearful most days, has stopped enjoying teaching and cooking, wakes at 4 a.m., has lost 5 kg, feels guilty that her students are 'suffering because of me', and has told her sister, 'They would manage without me.' She has no history of elevated mood, no hallucinations, and no medical diagnosis; thyroid function is normal. She drinks two pegs of whisky most nights 'to switch off' and has missed eight school days. Her father was treated for depression. She asks, 'Am I just stressed, or is this a disorder? Will tablets make me an addict?' The counsellor is a school counsellor, not a psychiatrist.
1. Which features push this beyond ordinary stress toward a depressive episode, and which features must be ruled out before any label? Explain your reasoning.
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Features that push this beyond ordinary stress:
- Duration: seven weeks, well beyond a transient stress reaction and beyond the two-week minimum usually required for a major depressive episode.
- Pervasive low mood and tearfulness most days.
- Anhedonia: she has stopped enjoying teaching and cooking.
- Biological symptoms: early-morning waking (4 a.m.), 5 kg weight loss, appetite change.
- Cognitive symptoms: excessive guilt and worthlessness ('students are suffering because of me').
- Functional impairment: eight missed school days.
- Possible suicidal ideation: 'They would manage without me.'
These cluster together and are not explained by a single external stressor.
Features that must be ruled out before any label:
- Bipolar disorder: no history of elevated mood, increased energy, or decreased need for sleep; no psychosis reported.
- Substance-induced mood disorder: she drinks two pegs nightly; alcohol can cause or worsen depression, and the timeline matters. Nightly drinking to sleep is also a risk.
- Medical causes: thyroid function is normal, but anaemia, chronic illness, medication, and other conditions need medical review.
- Grief/bereavement, adjustment disorder, persistent depressive disorder, and normal sadness.
- Severity, psychotic symptoms, and risk need formal assessment.
The counsellor can recognise the pattern, screen, and refer - not diagnose. The safe formulation is 'probable depressive episode, severity and risk to be assessed by a psychiatrist', not a definitive label.
2. How should the counsellor respond to the suicide-risk statement and the question about medication? What should she not do?
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Suicide risk: ask directly, calmly, and without euphemism: 'Are you having thoughts of ending your life? Do you have a plan? Have you tried before? What has kept you going?' Assess intent, plan, means, past attempts, substance use, and protective factors (her sister, students, faith, future plans). Do not promise absolute confidentiality. If risk is imminent, do not leave her alone; involve a responsible family member with her consent if safe, arrange urgent psychiatric/emergency evaluation, document, and follow up. The statement 'They would manage without me' is a warning sign, not attention-seeking.
Medication question: the counsellor is not a psychiatrist and must not prescribe or advise for or against medication. She can explain that antidepressants are not addictive in the way opioids or alcohol are, but they can have side effects, take time to work, and need medical supervision; some people need them, some do not, and the decision belongs with a psychiatrist after assessment. She can help Sunita list questions for that appointment.
What not to do: say 'everyone feels stressed'; reassure that it will pass; promise secrecy; diagnose; recommend a specific drug or dose; tell her to stop drinking abruptly without medical advice if dependence is possible; delay referral. Ethical anchors: informed consent, confidentiality limits, competence, non-maleficence, and continuity of care.
3. Why is 'just stress' not a safe conclusion here, and why is 'depression' also not the counsellor's final diagnosis?
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'Just stress' is unsafe because it minimises a seven-week syndrome with biological symptoms, functional impairment, possible suicidal ideation, and nightly alcohol use. 'Stress' is a broad transactional concept, not a diagnosis; using it can delay assessment and treatment, and it can imply that she should simply cope better. It also ignores the risk signal.
But 'depression' is not the counsellor's final diagnosis either. Diagnosis requires a clinical interview, rule-outs (bipolar, substance-induced, medical, grief), severity assessment, and risk assessment. The counsellor's role is to describe, screen, refer, support, and monitor - not to label. A label without the authority and training to apply it can be stigmatising, can close off alternative explanations, and can create false certainty.
The defensible position: 'Your difficulties are real and serious enough to need a proper assessment. They are more than ordinary stress, but only a psychiatrist can confirm a diagnosis. Let us arrange that and plan support meanwhile.' This respects scope of practice, non-maleficence, and the client's autonomy.