Mr. Rodriguez is a 50-year-oldmachinist referred by his primary care physician (PCP) to treatdepression. He has been depressed for over 3 years since his wife’sdeath from colon cancer and his children “growing up and out of thehouse.” His depression is worsening. He has problems with decreasedappetite (unintentional weight loss of 15 lbs. over the last eightmonths), difficulty falling and staying asleep, irritability, poorconcentration, and anhedonia. His PCP prescribed paroxetine 3months earlier, but Mr. Rodriguez hasn’t noticed much improvementin his symptoms-even at a dose of 40 mg daily. He tellsyou he has trouble carrying out normal routines (ADL’s) and socialcommitments and tells you he could’ve prevented his wife’s death ifhe “just knew” the symptoms better. At times he wishedhe had passed away with her. He’s preoccupied with low back pain,and when asked about depression, he doesn’t understand thecorrelation between depression and pain; he’ll answer yourquestions, and he keeps telling you his back pain is the”problem.”
Mr. Rodriguez has a history of takingtramadol for low back pain (3 years ago) when his PCP decided tostop prescribing tramadol due to using the prescription tooquickly. In the past, he declined MAT (suboxone) and atthis time isn’t interested or a candidate for MAT(suboxone). He has had chronic low back pain related tohis job for the last 30 years. However, the pain is worsening overthe last eight months. He had taken ibuprofen or naproxen with somerelief, but he began having epigastric distress about three yearsago when using these medications, and his PCP recommendeddiscontinuing them. Once he stopped taking the NSAIDs, theepigastric distress resolved.
- When you ask about his back pain, Mr. Rodriguez replies that heis willing to talk about it but doesn’t see how it’s relevant tothe depression for which he was referred to you. What would yourresponse be to Mr. Rodriguez?
2. What are two DSM-5diagnoses you would consider for Mr. Rodriguez? Explain yourrationale.
3. What are the questionsyou plan to ask him and screen for? What is Mr.Rodiriguez at risk for?
4. After reviewing his medication, youfeel that a trial of a different antidepressant is indicated. Whatmedication would you start him on? Why? Include the name (genericand brand), dose, route, and frequency/timing for allmedications.
5. The patient mentions hehad taken diazepam that his wife had been prescribed during herterminal illness to help him sleep. He asked his PCP to prescribediazepam for him, but she was hesitant and suggested he discussthis with you. How should you proceed regarding sleep hygieneeducation and medication?
6. List at one therapy andone nonpharmacologic recommendation for Mr.Rodriguez? Explain your rationale.
