Advanced Psychopharmacology

Depression Case Study Transcript

Chief Complaint: Mrs. Lane is a 42-year-old South Korean American female who presents stating, “I’m just so sad, I cannot stop crying. My primary care provider sent me because she says I am depressed, and she started me on Lexapro.”

History of Present Illness

Onset: Past three months worsening of moods, no interest in going out, seeing family, or cooking.

Location: Is distracted at home.

Duration: Depression was diagnosed by primary care provider two years ago.

Characteristics: Mrs. Lane reports that she has a history of major depressive disorder and generalized anxiety disorder, which is recurrent and was diagnosed by her primary care provider three years ago.

She reports that she was started on Lexapro 10 mg and felt somewhat better, until the last couple of months when, she states, “I just feel off.” She has a depressed mood and her affect is congruent. She has difficulty falling asleep and staying asleep, as she wakes most nights in the middle of the night.

Her appetite is the same, but she has a great deal of trouble concentrating on tasks and her memory is worsening. Her memory issues worry her the most, and she inquires if she should be tested for Alzheimer’s disease.

Mrs. Lane also states she lacks motivation to cook for her family and has not had them to her house for a meal for three months. Her favorite day of the week used to be Saturday, when she cooked for her entire family.

Aggravating: With stress and less sleep.

Relieving: Sometimes reading in bed and talking to family during the daytime helps.

Temporal: Worse in the a.m. at first waking and at bedtime before sleep.

Severity: I feel sad a lot and like everything is in gray shades. I think I’m getting worse.