E-Case #13

Victoria Allen, M.D.

April 2-6, 2001

A 40-year-old man presented to clinic to establish care and discuss symptoms of depression.  The patient was currently unemployed and had been suffering from symptoms of worthlessness, emotional liability, mood swings and difficulties with anger management.  Other symptoms included difficulty sleeping, decreased concentration and dysphoria.  The patient did have suicidal ideation but firmly denied intent, and expressed a strong desire and motivation for treatment.

The patient's past medical history was unremarkable; he was taking no medication or drugs.

The patient's family history was strongly positive for depression, his maternal grandfather had suffered from depression and committed suicide, his mother had a long history of depression requiring intermittent hospitalization and there was a brother with depression.

A detailed review of systems revealed no significant weight loss, feelings of decreased energy, tremulousness, palpitations and anxiety. Over an hour was spent with the patient assessing depression symptoms and suicidal risk.  The physical examination was deferred for one week,screening laboratories were ordered, and the patient was given a one week supply of Celexa 20 mg a day and asked to return to clinic in one week for further evaluation.

What screening laboratories would you order?

What follow-up plan would you initiate with this patient?

Discussion of E-Case #13

Depression is a common diagnosis in the primary care setting with estimates of 5-10% of patients with major depression and 12-20% having minor depression.  The differential diagnosis is broad including stroke, diabetes,dementia, cancer, hypothyroidism, chronic fatigue syndrome, fibromyalgia,systemic lupus erythematosus, coronary artery disease, corticosteroid use,and related anxiety and panic disorders.

Current recommendations regarding screening for underlying medical causes of depression include a complete physical examination, a mental status examination if significant memory impairment is an issue, and limited laboratory evaluation including a TSH, electrolytes, complete blood count,and consideration of folate, vitamin B12 and EKG if indicated.

The following laboratories were ordered: Hematocrit = 42.6, electrolytes(chem 7) were normal, and TSH was < 0.010.The physical examination was performed one week later:  HEENT  normal, nolid lag, no proptosis EOM normal.  Diffuse thyromegaly without pain or nodule.  CV diffuse PMI with a slight heave and 1-2/6 systolic murmur at RUSB.  Chest with slight left-sided gynecomastia otherwise normal. Extremities warm, DTRS hyperflexic.

The patient reported already feeling better on the Celexa and the results of his blood tests were discussed at length.

A telephone consultation was obtained with Dr. Maureen Marshall(Endocrinologist) regarding further workup and treatment of hyperthyroidism felt to be consistent with Grave's disease.  The patient had further laboratory testing which showed a Free T4 uptake of 31.82 (6.0-11.8), T4total 21.0 (4.5-12.0) and T3Uptake of 0.66(0.65-1.3).

The patient was started on Propanolol 20 mg tid and PTU 100mg tid and is continuing weekly visits to monitor both his depression and Grave's Disease.

With the diagnosis of depression, this case reminds us of the importance of a complete evaluation including the complete physical examination and appropriate laboratory testing as part of the initial workup and treatment plan.

Successful treatment of depression in the primary care setting includes a clear follow-up plan with the patient including frequent office visits everyone to two weeks for the first two months.  During this time monitoring of symptoms and drug side effects are discussed and consideration for changes or consultation if no improvement occurs in the first eight weeks. Appointment frequency and consistency is the most important factor in compliance of medical therapy and the general recommendation is the two week interval for the first two months of medical therapy.

References

Martin LM, Fleming KC, Evans JM.  Recognition and management of anxiety and depression in elderly patients.  Mayo Clin Proc 1995;70:999-1006.

Majeroni BA, Hess A.  The pharmacologic treatment of depression. JAMA1998;11127-139.