Running head: MULTIPE SCLEROSIS
Clinical Reasoning 2, Multiple Sclerosis
Margaret Heidenreich
Clinical Management III
University of Akron
Clinical Reasoning 1

Clinical Reasoning 2
Soap Note
Demographics : Caucasian 38yrs female on social security, single
CC: Fatigue
HPI: Jane Doe presents with a month long history of fatigue. She has history of MS for 5 years.
Jane doe states, “it seems like I have a lot less energy than normal, I’ve been sleeping more often sometimes 12 hours a day, and by the end of the day I’m really exhausted especially if I did something like cleaned or went to the store.” Jane Doe states does have some loss of interest in activities she normally enjoys but denies any thoughts of suicide.
PMH : hyperlipidemia 2011, MS 2008
SH: none
FH: mother- MS, htn, hyperlipid, deceased at 65 yrs, Father- htn, living 72yrs
Allergies: None, environmental, drug or food
Social History: No smoking history, drinks alcohol rarely, on special occasions
Health Maintenance: Up to date with pap smears, flu vaccine
ROS:
General: No n/v, fevers, Positive unintended weight loss 5 lbs
NEURO: Denies LOC, denies memory problems, denies muscle weakness, denies parasthesias
HEENT: Negative for frequent headaches, no vision changes or disturbances, no hearing changes, no nose bleeds or other nasal discharge
NECK: Negative for lumps, goiter , pain, negative for significant swelling
Respiratory: Negative for Cough, SOB, or wheezing
Cardiovascular: Negative for chest pain, palpitations, swelling
ABD: Negative for pain, changes in bowel patterns, red/black in stools, or heart burn
Skin: negative for rash or itching.
All other reviewed and negative other than HPI
Physical Exam
Vitals: B/P: 123/72 Pulse 68, SpO2 100%, Ht: 5’5”, WT 145 lbs,
General Appearance: Middle aged white female Alert in no apparent distress
Head: Normacephalic, no contusions, ecchymosis, or masses noted
Eyes: pupils are round and reactive to light. Extraocular movements are intact.
Ears external ears normal, canals clear, TM’s normal.
Nose/sinuses: negative
Oropharynx : lips, mucosa, and tongue pink and moist, teeth and gums normal

Clinical Reasoning 3
Neck: supple no adenopathy: thyroid symmetric no nodules palpated, no bruits
Lungs: Clear to Auscultation no adventitious sounds
Heart: RRR without murmur, gallop or rubs. No ectopy
ABD: Soft, not tender, no pain with palpation, BS positive in all quadrants
Neuro: CNS II-XII grossly intact, full sensations intact.
Co-Morbidities
Optic Neuritis
One Co-Morbidity found in up to 20% of MS patients is optic neuritis (Goroll & Mulley,
2009). Optic neuritis is defined as inflammation of the optic nerve (Goroll & Mulley, 2009). It has been found that 20-50% of patient who present with this symptom will eventually be diagnosed with multiple sclerosis (Goroll & Mulley, 2009). Signs and symptoms are progressive loss of eyesight usually in one eye that happens in hours to days. There is pain with movement of the eye and vision will begin to improve after two to three weeks (Goroll & Mulley, 2009).
Physical exam findings will include an afferent papillary defect, large vein congestion, blurred disc margins, decreased color vision, visual field problems and globe tenderness (Goroll &
Mulley, 2009, Buttaro). The optic nerve often looks normal in these cases (Goroll & Mulley,
2009). Treatment includes immediate referral to ophthalmology (Buttaro, Trybulski, Basiled, &
Sandberg-Cook, 2008).
Depression
Depression is another Co-morbidity of MS that Jane Doe is at risk for. Depression is very common in MS patients. Some studies even suggest that MS patients are up to 7.5x more likely to suffer from depression than the general population (National Multiple Sclerosis Society
(NMSS), 2013). Depression is a multi system disease affecting psychological, cognitive, neuroendocrine and neurotransmitter systems (Goroll & Mulley, 2009). Signs and symptoms

Clinical Reasoning 4 include sadness, loss of interest, decreased libido, sleep changes, frustration, worry, and thoughts of death and suicide (Goroll & Mulley, 2009).
Several lab tests should be done to rule out other causes of depression. A TSH level should be taken because hypothyroid and hyperthyroid can cause depression (Goroll & Mulley,
2009). A BMP should be taken as well because hypercalcemia, hypnoatermia and diabetes can also cause depression (Goroll & Muelly, 2009). Last, vit B12 and vitamin D levels should be drawn because deficiency of these vitamins can also cause depression (Goroll & Mulley, 2009).
NICE guidelines suggest that diagnosis of depression should include asking two depression questions: “During the last month, have you often been bothered by feeling down, depressed or hopeless?” and “During the last month, have you often been bothered by having little interest or pleasure in doing things” (2004). If the patient answers yes to either of these questions a formal mental assessment should be done and validated tools should be used such as the Patient Health Questionnaire-9, Becks Depression Inventory, or the Hospital Anxiety and
Depression Scale (Louch, 2009). Also, evaluation of suicide should always be done in every patient with known or suspected depression on every visit.
Treatment for depression depends on the severity of the disease. NICE recommends for mild to moderate depression to offer sleep hygiene, self-help guided by cognitive behavioral therapy, computerized cognitive behavioral therapy, and referral to psychology or counseling.
Medications should not be given to patients with mild depression unless they have a history of major depression, mild depression for two years or more, or the depression continues because of failure of other suggested interventions (2004). Drugs of choice should depend on other medications currently being used by the patient and potential side effects. First line suggestions

Clinical Reasoning 5 include generic SSRI’s including fluoxetine (20-40mg daily), sertraline (50mg daily to start 100-
250mg daily for maintenance), paroxetine (20-60mg daily), fluvoxamine 50mg to start, 100-
250mg daily for maintenance), citalopram (20-40mg daily) and escitalopram (10-20mg daily) can be given as initial treatment starting with the lowest dose (goroll & Mulley, 2009). The patient should always be educated that it can take 3 to 4 weeks to be effective (Goroll & Mulley,
2009). Side effects include increased agitation, insomnia, and anxiety, tremor, insomnia, sedation, mild weight gain, nausea, headache, and diarrhea (Goroll & Mulley, 2009). Fluoextine, paroxetine, and fluvoxamine interact with cytochrome P450 enzymes and should not be used in patients taking coumadin, phenytoin, or other drugs that interact with this system (Goroll &
Mulley, 2009).
Intention Tremor
Another common Co-morbidity of multiple sclerosis is cerebellar deficits such as intention tremor (Goroll & Mulley, 2009). Cerebellar deficits include intention tremor, limb weakness, and lack of muscle coordination (Goroll & Mulley, 2009). Intention tremor is defined as “rhythmic oscillations with motion” (Butarro, et al., 2008). Signs and symptoms may include patient complaints of involuntary or strange body movements, problems getting started or stopping movements, and these may worsen with increased stress or fatigue (Butarro, et al.,
2008). A thorough drug and alcohol history should be taken as some medications and drugs can worsen symptoms while alcohol can sometimes improve them (Butarro, et al., 2008). In addition, aggravating and alleviating symptoms should be discussed as well as time of onset, duration of symptoms, and when the symptoms first started (Butarro, et al., 2008). Physical exam should include a complete neurological exam and other systems involved (Butarro, et al, 2008). In addition, a detailed description of the movements as well as whether the movement is present at

Clinical Reasoning 6 rest or with movements is crucial (Butarro, et al., 2008). Deep tendon reflxes, Babinski and
Romberg’s signs may be decreased (Butarro, et al., 2008). Rapid movement testing and finger to nose testing should be done which may show rhythmic tremor or jerky and overcorrected movements (Butarro, et al., 2008). Diagnosis includes a CT scan or MRI of the brain to rule out tumors and lesions, EMG for diagnosis of the tremor that is present, and a thyroid panel should be drawn (Goroll & Mulley, 2009). Medications that can help intention tremor include low dose beta-blockers, primidone, baclofen, gabapentine, and benzos (Goroll & Mulley, 2009). Using wrist weights sometimes help with tremor as a non-pharmacological intervention (Goroll &
Mulley, 2009).
Urge Incontinence
Urge incontinence is a last Co-Morbidity that is found in patients with MS. Urinary problems occur including urgency, frequency, and incontinence from nerve injury in the upper spinal cord (Goroll & Mulley, 2009). Urge incontinence results from decreased bladder capacity and from cortical inhibition of the detrusor muscles working improperly (Goroll & Mulley,
2009). Signs and symptoms include warning sensation of need to urge only seconds before incontinence. This incontinence can be of various volumes, and sometimes while sleeping
(Goroll & Mulley, 2009). History questions should include frequency of events, when events occur, amount of urine lost, and what medications are being taken (Goroll & Mulley, 2009).
Physical exam should include palpation of the bladder post voiding, as well as having the patient do a Valsalva maneuver to evaluate stress incontinence (Goroll & Mulley, 2009). Superficial vaginal exam and the bulbocaverosus reflux should both be checked, and last, perineal sensation should also be checked to rule out autonomic reflex arc, sphincter tone changes, and lesions in the spinal cord (Goroll & Mulley, 2009).

Clinical Reasoning 7
Labs should include urinalysis and C&S to rule out infection. Treatments exist including restricting fluids, and natural diuretics like coffee, tea and alcohol (Groll & Mulley, 2009).
Patients should try to avoid caffeine products, use absorbent pads, and avoid catherization (goroll
& Mulley, 2009). Patients should be taught bladder-training programs learning to frequently empty their bladders to avoid urge incontinence. Kegel exercises should also be taught, and the use of bedside commodes and urinals can be useful (Goroll & Mulley, 2009). Medication that can be trialed include tricyclics with anticholinergic properties like imipramine (10mg 1 to 4 times daily), smooth-muscle relaxants like oxybutynin (2.5mg three times daily), or selective bladder smooth-muscle relaxants like tolterodine (1mg twice daily) (Goroll & Mulley, 2009).
Presumed Diagnosis
The presumed diagnosis for Jane Doe is depression secondary to MS. Jane doe presents with several features of depression including fatigue, weight loss, loss of interest in hobbies and changed sleep pattern. Depression is a common Co-Morbidity of MS because of several different factors including stress from disease diagnosis and progression or damage to the emotion centers of the brain directly causing these changes (NMSS, 2013). Another reason for depression in MS includes disease related changes in the immune and neuroendocrine systems
(NMSS, 2013). The patient has some negative risk factors for depression including no familial history of depression and no history of drug or alcohol abuse (Goroll & Mulley, 2009). At this time Jane Doe presents with remitting MS disease that is common in younger patients. This disease course is hallmarked by attacks that are followed by complete or near complete remission
(Goroll & Mulley, 2009). Co-Morbidities or residual problems usually stay stable between episodes (Goroll & Mulley, 2009). Jane presents with no other Co-Morbidities of MS at this time including those described above.

Clinical Reasoning 8
Plan of Care
Multiple Sclerosis (340) – Condition Stable

Give Jane Doe education regarding multiple sclerosis and disease progression, helpful tips (Appendix A)

Referral to support group through Multiple Sclerosis Foundation or Facebook

Encourage patient to continue healthy diet and exercise to maintain strength (UCSF,
2013)
Depression/Major Depressive Affective Disorder Single Episode unspecified degree (V79.0)-
Condition Stable

Labs: TSH, CBC, BMP, vitamin D 25hydroxy, Vitamin b12

Screening for Depression (V79.0)- Patient Health Questionnaire-9

Give education regarding depression (Appendix B)

Referral to psychologist specializing in depression in MS patients

Fluoexetine 20mg daily #30, no refills
Follow up Appointments
1.
Follow up in 1 week to go over lab results, make sure patient has made appointment with psychologist, evaluate medication adherence, re-evaluate dperession and problems or concerns the patient may be having at this time. a.
Primary Prevention- Tdap booster b.
Secondary Prevention- Screening for hyperlipidemia c.
Tertiary Prevention- Evaluate medication adherence, educate patient not to stop medication “cold turkey”
2.
Follow up 4-6 weeks to evaluate medication effect, re-evaluate patient mood. Adjust medication dosage as needed. a.
Primary Prevention- pneumonia vaccine b.
Secondary Prevention- Screening for hypertension c.
Tertiary Prevention – referral to psychiatrist if unable to regulate mood.
Research Question
Is yoga a beneficial exercise technique for multiple sclerosis patients? Yoga seems to have many different applications both for you young fit individuals, athletes and the elderly in nursing homes. In addition it has some relaxation benefits and would be helpful for the patient

Clinical Reasoning 9 with depression as well. Yoga has in fact been studied on patients with MS while looking at affects it has on different symptoms including neurogenic bladder, stress, and spasticity
(Velikonja, Curic, Ozura, & Jazbec, 2010). Studies suggest that yoga may have positive effects on these situations and may be possibly considered in the future as an adjunct to therapy, however more studies are needed before this could become an evidenced based recommendations (Rahnama, et. al., 2011; Prichard, Elison-Bowers, & Birdsall, 2010).
Soap Critique
Jane Doe came in with the initial complaint of fatigue. An in depth history of the patients symptoms was gathered and the patient’s physical exam was grossly negative except for weight loss. I asked the two initial screening questions of loss of interest in activities and suicide plans and then discussed the patient with my preceptor. No screening tool for depression was used at this point however I would’ve preferred to use one. I did not think the use of an anti-depressant was needed at this time, however my preceptor offered it to the patient who accepted it. I do agree with the use of an SSRI however I would’ve preferred to refer the patient to a psychologist since her situation is more complex and since psychotherapy can be as effective as medication
(Goroll & Mulley, 2009). Fluoexetine is a good medication choice because it can help both with fatigue from MS in addition to underlying depression (Goroll & Mulley, 2009). Perhaps the dual use of psychotherapy and medications would be the best solution however a psychologist would be proficient at making this decision especially one that specializes with MS patients.
I suggested the labs to be drawn that would rule out organic causes of the depression. I was not fully aware of the implications of MS on depression and the multitude of ways that the disease process can cause depression. However after further research it would be hard to distinguish what is specifically causing the depression in this type of patient so the plan of care

Clinical Reasoning 10 for diagnostics was sufficient. The patient previously had MRI scans due to her MS so these ruled out any tumors in the brain that could cause depression. A new lesion could be causing the depression but using a MRI for diagnosis would not change the treatment plan and would not be beneficial for the cost.
The patient has had MS for five years with two exacerbations during this time. She has had no residual problems at this point. She was somewhat educated on the topic, however no new educational material was given to her at the time. I wish I would’ve had more time to research and give her more education as this is proven to help the patient have a better feeling of control over their lives with the more knowledge they have (Goroll & Mulley, 2009). This could also help reduce any anxiety and perhaps helped the depressive characteristics as well.

Clinical Reasoning 11
References
Buttaro, T. M., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2008). Primary Care: A collaborative practice . (3 rd
ed). St Louis, MI: Mosby
Goroll, A.H., Mulley, A.G. (2009). Primary care medicine: Office and evaluation of the adult patient. Philadelphia, PA: Lippinicott Williams & Wilkins.
Louch, P. (2009). Diagnosing and treating depression. Practice Nurse, 37 (10).
National Institute for Health and Clinical Excellence (NICE). (2011). Donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease.
Retrieved from http://guidance.nice.org.uk/TA217 .
National Institute of Mental Health (NIMH) (2013). Depression. National Institute of Health
(NIH). Retreived from http://www.nimh.nih.gov/health/topics/depression/index.shtml.
National Multiple Sclerosis Society (NMSS) (2013). Depression. Retrieved from http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-aboutms/symptoms/depression/index.aspx.
Prichard, M., Elison-Bowers, P., & Birdsall, B. (2010). Impact of integrative restoration (iRest) medidation on perceived stress levels in multiple sclerosis and cancer outpatients. Stress
& Health: Journal of the International Society for the Investigation of Stress, 26 (3), 233-
237. Doi:10.1002/smi.1290.
Rahnama, N., Namazizadeh, M., Etemadifar, M., Babaeichi, E., Arbabzadeh, S., & Sadegipour,
H. (2011). Effects of yoga on depression in women with multiple sclerosis.
Isfahan Medical School, 29 (136), 1-8.
Journal of
University of California San Francisco Medical Center (UCSF) (2013). Living with multiple sclerosis. Retrieved From: http://www.ucsfhealth.org/education/living_with_ multiple_

Clinical Reasoning 12 sclerosis/index.html.
Velikonja, O., Curic, K., Ozura, A., Jazbec, S. (2010). Influence of sports climbing and yoga on spasticity, cognitive function, mood, and fatigue in patients with multiple sclerosis.
Clinical Neurology and Neurosurgery. 112
10.1016/j.clineuro.2010.03.006.
, 597-601. Doi:

Clinical Reasoning 13
Appendix A
If you have multiple sclerosis (MS), exercise can help retain flexibility and balance, promote cardiovascular fitness and a sense of well-being, and prevent complications from inactivity.
Exercise also helps regulate appetite, bowel movements and sleep patterns.
Jogging, walking and aerobic exercises are helpful when strength and coordination are not affected. Stationary bicycle riding may be more practical if walking or balance is impaired.
Swimming is helpful for stretching and cardiovascular fitness. Yoga and Tai Chi are most useful for stretching and promoting a sense of well-being. Your physical and occupational therapists will assist you in selecting the best exercise program for you to follow.
Although stress cannot be totally eliminated from our lives, we can learn to manage it more effectively. Any reduction in stress will be associated with an improved sense of well-being and increased energy. A psychologist or social worker may be helpful in developing a stress management program that is tailored to your needs. The following are some useful stress reduction techniques:




Identify causes of stress in your life and share your thoughts and feelings.
 Simplify your responsibilities by setting priorities.
Try relaxation and meditation exercises.
 Manage your time and conserve your energy.
Ask for help when needed.
Set both short-term and life goals for yourself.
 Keep as active as possible both physically and mentally.
 Recognize the things that you cannot change and don't waste your time trying.
 Make time for fun activities and maintain your sense of humor.
Good nutrition maximizes your energy, general sense of well-being and healing capacities. A dietary routine also contributes to regular bowel habits. Although no specific diet has been demonstrated to conclusively improve the natural history of MS, most people do report an improved sense of well-being when following a carefully planned diet. Several published diets are healthful and easy to follow. Others are more restrictive and less practical.
Unless there is a specific vitamin deficiency found by your doctor there is no scientific proof that supplementary doses of vitamins or minerals, alone or in combination, favorably affect the course of the disease. Be careful not to take excessive doses of vitamin B6 because excessive

Clinical Reasoning 14 doses of this vitamin can produce sensory symptoms similar to those seen in MS. High doses of vitamin A and D are toxic.
These fatty acids have been reported to be deficient in MS patients. There is an unconfirmed suggestion that supplementary feeding of these fatty acids may slightly reduce the frequency of
MS attacks. These fatty acids are contained in sunflower seed oil and primrose oil. The former is much cheaper and readily available in grocery stores. Two tablespoons of sunflower seed oil each day will provide you with these fatty acids and give you the added benefit of a laxative.
If you have problems with mobility, muscle contractures or are confined to a wheelchair, you should check your skin regularly for sores, pressure spots, infections and abrasions. Regular skin care will minimize the chances of skin breakdown and help you to avoid complications such as a decubitus ulcer. Be sure to check the pressure points on your body including your heels, knees, hips, buttocks and elbows. Remember to protect against skin cancer by wearing sunscreen and protective clothing when outdoors, whether it is sunny or not. Get familiar with your skin and examine it frequently.
Vitamin C helps to acidify the urine and prevent the growth of bacteria. Orange juice or vitamin
C tablets are both useful. Cranberry juice also will acidify the urine and is available as a sugar free juice for those who count calories. If you develop new urinary frequency, burning when you urinate or have difficulty passing your urine, you should call your doctor and be seen for the possibility of a urinary tract infection.
There has traditionally been a concern that immunizations could worsen MS by stimulating the immune system. With the exception of transient worsening associated with fever or rare neurological complications known to be associated with certain vaccines, there is no convincing evidence that immunizations make MS patients worse. If immunizations are recommended by a doctor, they can probably be undertaken safely. In general, immunizations should be delayed if the person is experiencing an acute MS attack. However, in some circumstances, such as when urgent vaccinations for tetanus or rabies are required, immunizations should be given immediately. If questions arise, you should discuss them further with your neurologist.
Physical Therapy (PT) focuses on ways to preserve or improve safety and independence with functional mobility. This may be accomplished through a variety of approaches including:
 Mobility technique training

Clinical Reasoning 15



Home exercise programs
Caregiver training
Effective use of adaptive equipment
The following are examples of PT therapeutic strategies that help everyday management of mobility-related symptoms.
Exercise Categories
You and a physical therapist should develop an individualized exercise program that is based on your current needs and future goals. This may include yoga, exercises in a gym, tai chi or
Feldenkrais, as well as traditional forms of exercise such as running, walking, biking, swimming or water aerobics. In some cases, exercises can be carried out independently, with or without modification. In other instances, certain more challenging exercises may require some assistance.
Stretching
Frequently, persons with MS have spasticity, especially in their lower extremities. This can cause the legs to stiffen if a regular stretching program is not incorporated into the daily routine of activities. Stretching exercises help to maintain or improve muscle length to allow greater flexibility.
Coordination
Coordination exercises are done to improve balance and ease of purposeful movement. The degree of skill required to perform the exercises varies. An appropriate program will be discussed with the individual MS patient.
Strengthening
Strengthening exercises are designed to build weakened muscles to aid in moving and walking.
While being beneficial, discretion is advised when carrying out a strengthening program. For instance, if one has undergone a vigorous session of exercising but is too tired to prepare dinner or do chores that ordinarily can be done without difficulty, it may be necessary to modify the program or space the activity more evenly throughout the day.
Upper Body Exercises
These simple exercises are designed to promote flexibility and muscle balance as well as to enhance upper extremity function. If done correctly, they are appropriate for all stages of MS.
Stretches are to be done slowly, generally being held for approximately five to 10 seconds. These exercises can be performed either seated or lying on your back. Repeat each exercise five to 10 times on each side as tolerated. You can do one side at a time or both sides at the same time.
(University of California San Francisco Medical Center, 2013)

Clinical Reasoning 16
Appendix B
Everyone occasionally feels blue or sad. But these feelings are usually short-lived and pass within a couple of days. When you have depression, it interferes with daily life and causes pain for both you and those who care about you. Depression is a common but serious illness.
Many people with a depressive illness never seek treatment. But the majority, even those with the most severe depression, can get better with treatment. Medications, psychotherapies, and other methods can effectively treat people with depression.
There are several forms of depressive disorders.
Major depressive disorder, or major depression, is characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy oncepleasurable activities. Major depression is disabling and prevents a person from functioning normally. Some people may experience only a single episode within their lifetime, but more often a person may have multiple episodes.
Depression is a common but serious illness. Most who experience depression need treatment to get better.
Dysthymic disorder, or dysthymia , is characterized by long-term (2 years or longer) symptoms that may not be severe enough to disable a person but can prevent normal functioning or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes.
Minor depression is characterized by having symptoms for 2 weeks or longer that do not meet full criteria for major depression. Without treatment, people with minor depression are at high risk for developing major depressive disorder.
Some forms of depression are slightly different, or they may develop under unique circumstances. However, not everyone agrees on how to characterize and define these forms of depression. They include:
 Psychotic depression , which occurs when a person has severe depression plus some form of psychosis, such as having disturbing false beliefs or a break with reality
(delusions), or hearing or seeing upsetting things that others cannot hear or see
(hallucinations).
 Postpartum depression , which is much more serious than the "baby blues" that many women experience after giving birth, when hormonal and physical changes and the new

Clinical Reasoning 17
 responsibility of caring for a newborn can be overwhelming. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.
1
Seasonal affective disorder (SAD) , which is characterized by the onset of depression during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not get better with light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.
2
Bipolar disorder , also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar disorder is characterized by cycling mood changes—from extreme highs
(e.g., mania) to extreme lows (e.g., depression). More information about bipolar disorder is available.
People with depressive illnesses do not all experience the same symptoms. The severity, frequency, and duration of symptoms vary depending on the individual and his or her particular illness.
Signs and symptoms include:
 Persistent sad, anxious, or "empty" feelings
 Feelings of hopelessness or pessimism


Feelings of guilt, worthlessness, or helplessness
 Irritability, restlessness
Loss of interest in activities or hobbies once pleasurable, including sex


Fatigue and decreased energy
 Difficulty concentrating, remembering details, and making decisions
Insomnia, early-morning wakefulness, or excessive sleeping
 Overeating, or appetite loss
 Thoughts of suicide, suicide attempts
 Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.
I started missing days from work, and a friend noticed that something wasn't right. She talked to me about the time she had been really depressed and had gotten help from her doctor.

Clinical Reasoning 18
Other illnesses may come on before depression, cause it, or be a consequence of it. But depression and other illnesses interact differently in different people. In any case, co-occurring illnesses need to be diagnosed and treated.
Anxiety disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, panic disorder, social phobia, and generalized anxiety disorder, often accompany depression.
3,4
PTSD can occur after a person experiences a terrifying event or ordeal, such as a violent assault, a natural disaster, an accident, terrorism or military combat. People experiencing PTSD are especially prone to having co-existing depression.
In a National Institute of Mental Health (NIMH)-funded study, researchers found that more than
40 percent of people with PTSD also had depression 4 months after the traumatic event.
5
Alcohol and other substance abuse or dependence may also co-exist with depression. Research shows that mood disorders and substance abuse commonly occur together.
6
Depression also may occur with other serious medical illnesses such as heart disease, stroke, cancer, HIV/AIDS, diabetes, and Parkinson's disease. People who have depression along with another medical illness tend to have more severe symptoms of both depression and the medical illness, more difficulty adapting to their medical condition, and more medical costs than those who do not have co-existing depression.
7
Treating the depression can also help improve the outcome of treating the co-occurring illness.
8
(NIMH, 2013)