Mr. Rodriguez is a 50-year-old machinist referred by his primary care physician (PCP) to treat depression. He has been depressed for over 3 years since his wife’s death from colon cancer and his children “growing up and out of the house.” His depression is worsening. He has problems with decreased appetite (unintentional weight loss of 15 lbs. over the last eight months), difficulty falling and staying asleep, irritability, poor concentration, and anhedonia. His PCP prescribed paroxetine 3 months earlier, but Mr. Rodriguez hasn’t noticed much improvement in his symptoms-even at a dose of 40 mg daily. He tells you he has trouble carrying out normal routines (ADL’s) and social commitments and tells you he could’ve prevented his wife’s death if he “just knew” the symptoms better. At times he wished he had passed away with her. He’s preoccupied with low back pain, and when asked about depression, he doesn’t understand the correlation between depression and pain; he’ll answer your questions, and he keeps telling you his back pain is the “problem.”
Mr. Rodriguez has a history of taking tramadol for low back pain (3 years ago) when his PCP decided to stop prescribing tramadol due to using the prescription too quickly. In the past, he declined MAT (suboxone) and at this time isn’t interested or a candidate for MAT (suboxone). He has had chronic low back pain related to his job for the last 30 years. However, the pain is worsening over the last eight months. He had taken ibuprofen or naproxen with some relief, but he began having epigastric distress about three years ago when using these medications, and his PCP recommended discontinuing them. Once he stopped taking the NSAIDs, the epigastric distress resolved.
When you ask about his back pain, Mr. Rodriguez replies that he is willing to talk about it but doesn’t see how it’s relevant to the depression for which he was referred to you. What would your response be to Mr. Rodriguez?
What are two DSM-5 diagnoses you would consider for Mr. Rodriguez? Explain your rationale.
What are the questions you plan to ask him and screen for? What is Mr. Rodiriguez at risk for?
After reviewing his medication, you feel that a trial of a different antidepressant is indicated. What medication would you start him on? Why? Include the name (generic and brand), dose, route, and frequency/timing for all medications.
The patient mentions he had taken diazepam that his wife had been prescribed during her terminal illness to help him sleep. He asked his PCP to prescribe diazepam for him, but she was hesitant and suggested he discuss this with you. How should you proceed regarding sleep hygiene education and medication?
List at one therapy and one nonpharmacologic recommendation for Mr. Rodriguez? Explain your rationale.
