History of Present Illness
Ellen had first experienced anxiety and depressive symptoms two years earlier in the immediate aftermath of her father’s death. She had attributed this to the normal process of grieving. Ellen’s father had been drinking on the night of the accident, had driven off the road late at night, and died at the scene. A pedestrian was badly injured but survived. Ellen was tormented by her suspicion that her father’s death had not been an accident, that he had committed suicide. He had been under stress for some time following the collapse of his business and had been distressed, agitated, and drinking when speaking to her on the night of his death. This uncertainty complicated the task of mourning for Ellen and her family, and made her reluctant to discuss her loss with anyone. Ellen felt that her uncertainty about the circumstances of her father’s death prolonged her distress. She described trying not to think about it by keeping busy, and managed this for brief periods but inevitably returned to feeling low and anxious.
Twenty months after her father’s death, Ellen suffered a broken ankle in a cycling accident. Unable to work immediately after the accident, she experienced a marked increase in depressive symptoms that prevented her planned return a few weeks later. She lost all interest in social activities and became very withdrawn, very tearful and depressed, feeling preoccupied and guilty. Ellen told her mother that she wished she had died in the cycling accident and could be with her father again. She was encouraged to speak to her general practitioner (GP), who prescribed antidepressant medication and referred Ellen to a National Health Service primary care service for psychotherapy.