The challenge
Clara’s depression seemed straightforward.
A 35-year-old woman with chronic medical conditions (Ehlers-Danlos Syndrome, POTS, history of thyroid cancer), she presented with a PHQ-9 of 23—severe depression. She’d been treated for depression before without lasting improvement. The referral noted she wanted to understand if “previous traumatic patterns may be causing changes in expectations or behavior.”
Standard care would have tried another antidepressant.
What standard care would have done
Standard care would have diagnosed Major Depressive Disorder in the context of chronic medical illness, initiated or adjusted an antidepressant, and referred for general supportive therapy. Her positive MDQ screening might have been noted but likely dismissed given her medical complexity. The trauma she’d never disclosed would have remained hidden.
She would have received treatment that could have made her worse.
What Assess surfaced
Comprehensive assessment revealed why her depression had been “treatment-resistant”—it wasn’t just depression:
- Bipolar II unmasked from “good symptom days.” Clara’s MDQ was strikingly positive—10 of 13 manic symptom items endorsed. When asked about elevated mood episodes, she minimized them as “hyperstates” when her physical symptoms improved. Deeper exploration revealed historical periods of decreased sleep need, rapid speech, increased goal-directed activity—and reckless behaviors including meeting strangers from dating apps, going to hotel rooms, and accumulating significant debt.
- Sexual assault never disclosed. A 2020 assault on a second date emerged during the assessment. “All of a sudden it shifted and I was like, oh crap, I don’t know how far this is gonna go.” She never reported it. She blamed herself. It was still affecting her daily functioning.
- Childhood trauma creating dissociative patterns. 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.” She learned to “shut down and numb out”—a pattern that became automatic.
- Medical trauma as ongoing driver. Decades of not being believed by providers, culminating in an ER visit where she was paralyzed for 24 hours and told to “try harder to move.”
- Profound cognitive impairment. PROMIS Cognitive T-score of 22.41—nearly 3 standard deviations below the mean. Every item endorsed at maximum severity. This wasn’t just “brain fog.”
What changed
Diagnosis: Not treatment-resistant Major Depressive Disorder. Bipolar II Disorder with severe depressive episode, extensive trauma history, and cognitive impairment at the intersection of mood, migraine, and autonomic dysfunction.
Treatment: Instead of another antidepressant—which could have triggered mania—we recommended:
- Psychiatric evaluation for mood stabilizers (lamotrigine)
- EMDR for the layered trauma (sexual assault, childhood abuse, medical trauma)
- Weekly CBT
- Cognitive testing to characterize impairment
- Physical therapy through an EDS-informed provider
The trajectory changed fundamentally. Clara’s response: “I feel like I’m coming out of one of those long spaces of just existing.”
The outcome
Clara’s diagnosis changed from Major Depressive Disorder to Bipolar II. Treatment shifted from antidepressants (potentially destabilizing) to mood stabilizers plus EMDR for trauma. Fundamentally different trajectory.
”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, 35PHQ-9: 23 | MDQ: Positive
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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.
