CASE STUDY
A 51-YEAR-OLD MAN WITH RECURRING
MILD-TO-MODERATE DEPRESSION
—
Thomas W. Koenig, MD
BACKGROUND
A 51-year-old man was referred by his primary
care physician (PCP) to a psychiatrist in an officebased practice for treatment of recurring mild-to-moderate depression. Mr D. had been taking citalopram
40 mg for 1 year, prescribed by the PCP. His depressive symptoms were said to “wax and wane” during
this time, with his current episode considered to be
of moderate severity.
HISTORY
Mr D. is employed as a computer engineer for a
large national defense contracting company. He has
been employed at this company for 5 years and was
promoted to a managerial role approximately 8
months ago. He is happy with the more technical
aspects of his work but finds the managerial responsibilities frustrating. However, he was given a substantial
pay raise for this promotion and feels compelled to
continue as a manager, as his children will be attending college in the next couple of years.
Mr D. has been married for 21 years and has 3 children, a son aged 16 years and daughters aged 14 and
11 years. His wife is 50 years of age and a full-time
homemaker. He maintains that his marriage is “good.”
The rest of his family (siblings and parents) are scattered throughout the country, more than a 1-day drive
away. He maintains close relationships with his brother, sister, and parents and tries to see his parents at least
once per year. He and his wife are friendly with the
neighbors but do not socialize with them. They have
Advanced Studies in Medicine
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no friends in the area whom they would consider to be
“close” friends.
Mr D. is college educated and has a master’s degree
in computer science. He enjoys working in his yard
and reading in his spare time. He also stays physically
fit by swimming regularly and lifting weights several
times per week.
Other than his depressive illness over the past year,
Mr D. has not had any other psychiatric disorders. He
saw a psychological counselor briefly during college
when he was having difficulty with his grades. He and
his wife also sought marital counseling 12 years ago for
about 3 to 4 months, mostly due to the stress of frequent job changes and moving to new cities with 2
small children.
Mr D. has no significant medical conditions. He
has mild hypertension (130/85 mm Hg) and mild
hypercholesterolemia (209 mg/dL). He has no history
of surgical procedures, head trauma, or other major
medical conditions. He does not smoke. He has no
significant family history of any medical or psychiatric
disorder. His parents are living (in their late 70s) and
in overall good health.
TREATMENT HISTORY
Mr D. first presented to his PCP 1 year ago with a
3-week history of insomnia, poor appetite, anxiety,
and feeling “out of control.” He had lost 15 pounds
during that time. His wife had severe menopausal
symptoms, his teenage daughter was very rebellious at
the time, and he was under a lot of stress at work due
to cutbacks (resulting in a heavier workload) and disagreements with one of his several bosses. His PCP
diagnosed depression with some anxiety and prescribed citalopram 20 mg once daily. Mr D. returned
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CASE STUDY
to his PCP for a follow-up visit after 2 weeks with
minimal symptom improvement. He returned again
after another 2 weeks and reported sleeping better and
feeling less “weighed down” by his problems. His PCP
told him to continue with the citalopram 20 mg for
another 6 months.
He returned to the PCP at 4 months; his insomnia
had returned, and he had a general feeling of fatigue and
malaise. He also complained of overall achiness, and dyspepsia that had started several months ago. His PCP
increased the dose of citalopram to 40 mg once daily and
suggested eliminating caffeine from his diet and doing
more stretching or yoga as a relaxation method and to
relieve some of the achiness. He also prescribed esomeprazole 20 mg once daily for the dyspepsia. He asked Mr D.
to return in 2 weeks if the insomnia was not ameliorated.
Mr D. returned in 2 weeks with further complaints
of intermittent insomnia. By this time, he had started
his new position as a manager and was getting settled,
which helped with some of the anxiety, but he was
“desperate for some regular sleep.” His PCP prescribed
zolpidem as needed for his insomnia and referred him
to a psychiatrist to treat his recurrent depression.
Mr D. is currently taking citalopram 40 mg once
daily, zolpidem 10 mg as needed, celecoxib, and
metaxalone 400 mg as needed. His PCP also prescribed massage for his achy muscles, but he is uncomfortable with the idea of a massage by a stranger.
PSYCHOSOCIAL ASSESSMENT
FIRST SESSION
Mr D. feels that he is currently experiencing moderate stress at work. His workday is very full but manageable. His daughter’s teenage rebellion seems to have
settled down and his wife’s menopausal symptoms
have improved. He and his wife took a long vacation
this past winter by themselves, and he remarked on
how much he enjoyed that. He also said he and his
wife were making an effort to spend more time together, without the children.
SECOND SESSION
In the second session with the psychiatrist, Mr D.
was asked to again describe the symptoms that led him
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to seek treatment from his PCP. Mr D. then revealed
that his dyspepsia had started more than 1 year ago, as
did his sense of “overall aches and pains,” particularly
in the lower back (he did not offer this information at
the first session). He described his general malaise during that time as “feeling like lead” and being too tired
to really deal with anything. He felt he was “just barely getting through 1 day at a time.”
Although he felt the citalopram helped, especially when the dose was increased, he never really
seemed to be able to “shake off the depression.” He
remarks that he is unsure what the psychiatrist can
do because he is resistant to taking further medication. He attributes his poor sleep and dyspepsia to
stress at work and his low-back pain to being
hunched over a keyboard all day.
DISCUSSION
Mr D.’s diagnosis of mild depression appears to be
correct. His depressive symptoms over the past year
included insomnia, weight loss, poor appetite, feeling
out of control, and feeling “weighed down.” His
depression never seemed to resolve completely, despite
adequate doses of citalopram. Of note, the physical
symptoms present at his first PCP visit were not associated with the depressive symptoms, by either the
patient or the PCP. They did not resolve and, as a
result, Mr D. never felt able to “shake off the depression.” In fact, it took 2 sessions with the psychiatrist to
discover the extent of his physical complaints during
the past year.
Unresolved or undertreated depression is a useful
signal to probe for somatic complaints that may be
untreated. Mr D.’s somatic complaints are common
among those with depression: dyspepsia, malaise, achiness, and low-back pain. It is common for patients—
and even PCPs—to not associate the somatic
complaints (especially vague complaints with no
apparent discernible cause) with depressive symptoms.
In Mr D.’s case, an excuse for each symptom could be
found (anxiety over job stress for dyspepsia, poor posture at his desk for low-back pain). More aggressive
treatment of the patient’s depression may help to
resolve his lingering physical symptoms.
Vol. 4 (1A)
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January 2004