Case: Marsha Martin
Marsha Martin is a 38 year old female with a past medical history of seasonal allergies that is well controlled on loratadine. Her last annual exam was 9 months ago and all examinations and screening tests were normal. She comes to this follow up visit for several complaints she has been having over the past 6 months. Ms. Martin has been not been feeling “quite right” and this is her third visit to you in just 4 months. She has complaints of fatigue and low energy. Her menstrual cycles are normal in length and flow. Ms. Martin says she is not depressed and has no recent life events that have occurred. She states that she has the “same normal job stress as everyone else”.
Ms. Martin feels she has occasional awakening in the middle of the night with difficulty
falling back asleep. She complains of heart palpitations that come and go especially at night when she lies in bed awake – and is not associated with any chest pain or shortness of breath. She stopped drinking coffee as you suggested, and her recent EKG and thyroid stimulating hormone (TSH) were normal. She went to have a Holter monitor examination after a similar complaint prior at her last visit and she is here for the results.
In addition, Ms. Martin has been noticing for 6 weeks a dull pain that begins in her lower left leg and radiates up to her left upper abdomen once or twice a week. She can not associate the pain with any trauma, menstrual cycles, or precipitating factors (bending over, food consumption, bowel movements, etc.). She has had no specific point tenderness, no back pain, and no edema or skin changes anywhere. The pain lasts only 1 – 2 minutes and does not require any pain medications.
Past Medical History – Seasonal Allergic Rhinitis
Meds – Loratadine 10mg one tablet orally every day
Allergies – No known drug allergies
Past Surgical History – None
Gyn History – G0P0000, normal menstruation cycle and flow. No STDs history. All pap smears are normal. Not currently sexually active in >5 years. She is sexually interested in males only. Not using any birth control method.
Family History – Mother, 60 years old, has diabetes and asthma (and is your patient too).
Father, 62 years old, has hypertension only (and is your patient too).
Sister, 41 years old, has atopic dermatitis only (and is your patient too).
No history of mental health disease in the family.
Social History – Marsha Martin is employed as a department manager at the International Bank of Valsalva. She reports the job as stressful and that “there is a crisis going on all the time.” She is not in a relationship with anyone, and she broke up with her last male partner 5 years ago. She is financially “okay” but she pays a lot of rent living in New York City. She does not smoke or use recreational drugs of any kind, but does have one glass of wine at dinner. Ms. Martin admits that she is 100% invested in her job on weekdays. She admits she has lost interest in going out with friends; dropped out of her book club and a yoga class she used to enjoy about half a year ago; is not interested in starting any intimate relationships. On weekends she cleans her home and prepares for the next work week. She admits that although she has a good relationship with her family, they are worried about her since she has become less social over the past few months. Her family and co-workers feel she is more distracted these days especially during routine conversations. No recent travel history reported.
ROS –She admits that her appetite is less than prior and denies actively dieting and attributes her weight loss to job stress. Admits to less pleasure in doing things she used to like to do, but does not feel she is depressed or sad.
PE
BP 135/70 P68 R20 Wgt 150 lbs (was 170 lbs nine months ago)
General – In no acute distress
HEENT – within normal limits, No jugular venous distention, No thyromegaly or nodules
Lungs – clear to auscultation B
Cor – regular rate and rhythm, no murmurs, no pauses
Abd – Soft / non-tender, positive bowel sounds. No guarding or rebounding. No reproducible pain.
Ext – No clubbing / no cyanosis / no erythema. All extremities are full range of motion and no reproducible pain.
General Skin – Intact with no lesions or rashes.
Neuro – No tremors; reflexes 2+ upper and lower extremities; normal hand to nose coordination, normal gait – essentially a normal neurological exam.
MSE – She denies depression or sadness or anxiety. The patient denies suicidal ideation or homicidal ideation. She also denies hallucinations of any kind. No observable anxiety or psychomotor retardation. Affect mildly flat.
Labs -
Guaiacs Neg x 3
TSH 1.72 (WNL 0.34 – 4.25)
Chem 7 WNL
Hct 39
EKG – normal sinus rhythm, rate 75, no left ventricular hypertrophy
Holter monitor – Normal. No abnormal rhythm or pauses.
Question 1) Ms. Martin feels fatigued and “not quite right”. Her physical examination and lab work up are negative. She completely denies being depressed. Upon further questioning she does describe losing interest in activities she used to like to do, decreased appetite, unintentional weight loss, and occasional problems with insomnia. At this point, which is the most appropriate next step in assessing Ms. Martin? (Choose the one best answer.)
The correct answer is e. Ms. Martin has several classic signs and symptoms of depression (e.g. unintentional weight loss, insomnia, vague unexplained symptoms, and anhedonia) and performing a standardized screening questionnaire for major depression is appropriate to assist in making the diagnosis. Like most people suffering from depression, Ms. Martin does not complain of depressed mood. Although lupus may have depressive symptoms associated with it, it is less commonly seen in the primary care setting and although lupus can not be ruled out – the priority would be in conducting an effective depression screen. Likewise, unless this patient is having further evolving cardiac complaints or physical examination abnormalities, continued cardiac testing is not warranted. This is a similar rationale for not ordering an MRI of her abdomen, pelvis, and left leg at this time. Unless Ms. Martin is having further evolving leg - abdomen complaints or any physical examination abnormalities, an MRI would not be a cost effective next step. Unless the patient is having severe anxiety, prescribing diazepam would not be appropriate without first performing a depression screen. Prescribing sleeping medication without first screening the patient for depression is also not considered “best practice”.
Question 2) Marsha Martin agrees to complete a standardized screening questionnaire for depression. You have asked her both questions on the Patient Health Questionnaire – 2 (PHQ – 2) and you received a positive response when you asked her if she has little interest or pleasure in doing things; she has less pleasure or interest in doing things she used to enjoy (ex. book club, yoga, relationships). You go on to do the Patient Health Questionnaire – 9 (PHQ – 9) with Ms. Martin and she has the following responses:
PHQ – 9 Over the last 2 weeks, how often have you been bothered by any of the following problems? : Total Score: 10 |
According to the Patient Health Questionnaire – 9 depression screening, Ms Martin:
The correct answer is c. According to the Patient Health Questionnaire – 9 (PHQ – 9), Ms. Martin has checked off 5 boxes in the areas of the questionnaire that correspond to depressive symptoms that occur on more than half the days to nearly every day. In addition, one of these affirmative answers is from two sentinel questions: “Little interest or pleasure in doing things” and/or “Feeling down, depressed, or hopeless.” The total score for depression severity according to PHQ – 9 is:
Interpretation of Total Score
Total Score Depression Severity
0-4 None
5-9 Mild depression
10-14 Moderate depression
15-19 Moderately severe depression
20-27 Severe depressionMs. Martin should therefore be considered for a diagnosis of moderate depression. Since the questionnaire relies on patient self-report, all responses should be verified by the clinician and a definitive diagnosis made on clinical grounds, taking into account how well the patient understood the questionnaire, as well as other relevant information from the patient. Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social, occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms. (PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. Copyright ©1999 Pfizer Inc. All rights reserved. PRIME MD TODAY is a trademark of Pfizer Inc.).
Question 3) Ms. Martin has moderate major depression after you verify her responses to a standardized depression screening questionnaire (ex. PHQ – 9). After further assessment, she has no manic or hypomanic history or current symptoms; denies suicidal or homicidal ideation or plans; and her symptoms have not been persistent for more than 2 years at lesser or greater degree. This is her first episode of major depression. You review the appropriate treatment options with Ms. Martin and they include all of the following except:
The correct answer is d. For patients with mild to moderate depression, the initial modalities may include pharmacotherapy alone, psychotherapy alone, combination antidepressant medication and psychotherapy. In all cases of depression, psychiatric management of the patient must be done concurrently regardless of the treatment chosen. This can be done by the primary care physician, psychotherapist, and / or psychiatrist (Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients with Major Depressive Disorder. American Psychiatric Association. 2000). Electroconvulsive therapy is appropriate for first line treatment when there is severe depression with psychotic features, psychomotor retardation, or resistance to medications – and thus would not be an appropriate treatment option for Ms. Martin at this time (UK ECT Review Group, Lancet 2003).
Question 4) After her initial assessment, you and Ms. Martin have agreed to treatment using an antidepressant medication such as a selective serotonin uptake inhibitor (SSRI) for her first episode of moderate major depression. You have been seeing Ms. Martin on an ongoing basis for 7 months for her depression. She initially spent 12 weeks in the “acute phase” of treatment, getting her SSRI titrated up to an optimal level which resolved her depressive symptoms. She continues quite stable and free of symptoms in the “continuation phase” of treatment now for an additional 16 weeks. Ms. Martin wants to know if she can have her antidepressant medication discontinued. Appropriate counseling of this patient includes the following:
The correct answer is c. Ms. Martin is a 38 year female with her first major lifetime episode of major depression that is now asymptomatic after 7 months of antidepressant therapy. She has remained stable throughout the continuation phase and does not appear to be a candidate for maintenance treatment (ex. suicidal ideation or attempts, psychotic symptoms, functional impairment; history of recurrent depressive episodes), but patient preference for continuing their antidepressant treatment in the “continuous phase” into the “maintenance phase” is also acceptable (Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients with Major Depressive Disorder. American Psychiatric Association. 2000). The recurrence rate for patients with a single depressive episode is high around 50 – 85% thus patients must be counseled on the signs and symptoms of recurrent depression and should have periodic assessment by their clinicians. Depressive symptoms after discontinuation of antidepressant medications can be attributed to BOTH discontinuation syndromes because the medication was titrated too quickly or because of relapse into another episode of major depression. These are the reasons why patients who are terminating their antidepressant treatments should have ongoing surveillance.
Question 5) If during her antidepressant medication treatment, Marsha Martin told you that she had gone on impulsive and expensive shopping spree and engaged in several risky unprotected sexual encounters you would appropriately refer her to a psychiatrist because:
The correct answer is c. Although this patient has no family or personal history of manic or hypomanic symptoms, it is important for physicians to be monitoring patients on antidepressants for unrecognized bipolar disorders that present mistakenly as a unipolar disorder. Ms. Martin’s sudden behavior change is not consistent with dysthymic disorder, schizophrenia, or an undiagnosed personality disorder (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4 text revision, American Association, 2000. Washington DC).