The challenge
Clara’s depression seemed straightforward—PHQ-9 of 23 (severe depression) in a 35-year-old woman with Ehlers-Danlos Syndrome and POTS. She’d been treated for depression before without lasting improvement. Her presenting complaint was “focus/motivation/dissociation.” Standard care would have tried another antidepressant
What standard care does
Referral said :
- Depression and Anxiety
- Chronic illness context
Standard care would have diagnosed Major Depressive Disorder with comorbid anxiety in the context of chronic medical illness. Prescribe an SSRI. Refer for general therapy if available. Miss the bipolar pattern entirely—potentially destabilizing her with antidepressant monotherapy.
What we actually discovered
We determined:
- Bipolar II Disorder (F31.81)
- ADHD features requiring evaluation
- Complex trauma (childhood, sexual, medical)
- Eating disorder history (active in new form)
- Hidden Bipolar II: Our MDQ screening was strikingly positive—10 of 13 manic symptom items endorsed. Clara mentioned “hyperstates” when her symptoms improved. Further probing revealed historical episodes meeting hypomania criteria: elevated mood noticed by others, decreased sleep need without fatigue, increased goal-directed activity. Plus reckless behaviors: meeting strangers from dating apps, going to hotel rooms on second dates, accumulating significant debt. She’d rationalized these as “good symptom days.”
- Undisclosed Sexual Assault: A 2020 sexual assault Clara had never reported emerged during exploration. She blamed herself: “my naivety and stupidity contributed.” She’d never told anyone.
- Layered Trauma: Childhood physical abuse from her brother (“he had me up against the wall choking me and said it would be worth spending the rest of his life in jail if he could kill me”). Decades of medical trauma from providers who didn’t believe her symptoms.
- Profound Cognitive Impairment: PROMIS Cognitive T-score of 22.41—nearly 3 standard deviations below the mean. Every item endorsed at maximum severity.
The Treatment Plan
This diagnosis change wasn’t semantic—it fundamentally altered treatment:
- Mood stabilizers first (lamotrigine consideration), NOT antidepressants alone
- EMDR for trauma processing
- Weekly individual CBT
- Cognitive testing (Creyos)
- Neurofeedback consideration
- Sleep optimization
- Physical therapy through EDS-informed provider
The psychiatrist’s conclusion: “She’s bipolar until proven otherwise… She’s got all the stigmata of it. Reckless behavior, racking up credit card bills and excess spending, sexualizing…”
Impact by the numbers
Metric
Our Assessment
Industry Benchmark
”At least now I know there's an endpoint, there's a start point. Before was I don't know if I'm gonna go to school, when a job's gonna come... at least now I know
David, 72PHQ-9: 1, PROMIS Cognitive: Normal
Key insights
“All of a sudden it shifted and I was like, oh crap, I don’t know how far this is gonna go… And then he starts saying, ‘What are you gonna tell your friends? That wasn’t sex.’ And I realized: he knew what he did and was trying to gaslight me”
— Clara, 35, PHQ-9: 23, trauma surfaced during Exploration
The outcome
Ready to See What Assess Finds in Your Practice?
These findings came from real assessments at Texas Center for Lifestyle Medicine. We have detailed documentation on 50+ patient evaluations, with more being added from ongoing clinical work.
Request Practice Assessment
Let's explore whether Assess makes sense for your workflows
