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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify the signs and symptoms of depression.

  • Develop a pharmacotherapy plan for a patient with depression.

  • Compare side-effect profiles of various antidepressant drugs.

  • Discuss pharmacoeconomic considerations that must be taken into account when selecting antidepressant therapy.

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PATIENT PRESENTATION

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Chief Complaint

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“I don’t know if I can handle this anymore.”

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HPI

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Geneva Flowers is a 41-year-old woman who is referred by her family physician to an outpatient mental health clinic. She complains of feeling down and sad, with crying spells, trouble sleeping, increased eating, impaired concentration, and fatigue. She has not worked in over 2 months and has used up her vacation and sick leave from work.

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She went through treatment for alcohol use disorder over a year ago. Things were going fairly well for her after her treatment and she remarried approximately 8 months ago. Arguments with her teenage sons about family issues and past incidents have made her increasingly depressed over the past few months. Her older son, 17, moved out to live with his father. Her younger son, 12, moved to live with his paternal grandparents.

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She divorced the boys’ father after approximately 10 years of marriage when she discovered that he was having an affair with another woman. She left her second husband after approximately 2 years because of problems involving his children that caused increasing conflict with her then-husband. Without a second income in the household, she accumulated large credit card debts. She began drinking and soon developed a pattern of using alcohol to relieve stress. Just before entering alcoholism treatment, there was a sexual fondling incident involving one of her son’s friends while the friend was visiting her son at her house, but she was amnestic for the incident the next day. Her present husband, her third, has been supportive of her, but she feels guilty about her failed previous marriages and her sons, worries about her debt, and has become more despondent. She has taken a leave of absence from her job as an administrative assistant at an elementary school.

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The patient sought treatment for depression 3 months ago from her family physician, who prescribed mirtazapine. Her spirits have not improved, and she says the medication made her gain weight. Because of vague references that the physician believed could possibly indicate suicidal ideas, she has been referred for psychiatric evaluation.

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PMH

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  • Childhood illnesses: she has had all of the usual childhood illnesses. She was hospitalized at age 3 for bacterial meningitis but knows of no residual effects.

  • Adult illnesses: no current nonpsychiatric adult illnesses; no previous psychiatric treatment.

  • Trauma: fractured arm due to bicycle accident at age 9, otherwise unremarkable.

  • Surgeries: Hx childbirth by C-section; tonsillectomy at ...

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