Patient evaluation on intake

54-year-old woman with a chief complaint of “being depressed”

Patient started interferon treatment for hepatitis C and became alarmingly depressed

Psychiatric history

The patient had been psychiatrically healthy until she was treated with interferon

While on treatment she developed marked insomnia initially, which was then followed by more fulminant depression and anxiety symptoms

Now experiencing full MDD symptoms

• – Except that she denies suicidal thoughts but has ideational guilt that she is a bad spouse and mother and that she has let her family down by being incapacitated and unable to do much of anything around the home

• – Experiencing marked agitation and restlessness routinely during the day and has insomnia at night

• – Is very tired, fatigued, unfocused, and unmotivated

Does meet criteria for GAD prior to the onset of this MDE

• – Worries excessively

• – Is tense, keyed up, on edge

• – Has insomnia

• – Additionally admits to panic or agitation attacks that are sustained for hours

  • She did not experience these when euthymic, or prior to her interferon treatment

There is no evidence of psychosis, mania, substance misuse

Spouse and family are supportive

She has traveled to specific inpatient depression treatment programs for advice and brings her extensive workup to her initial session

Social and personal history

Graduated from college with a bachelor’s degree

Married and has a grown daughter

A school teacher by trade, but has been unable to teach

Does not misuse alcohol, caffeine, nicotine, or other drugs

Medical history

Chronic severe head, neck, and shoulder pain, which is now exacerbated by MDD

A report showing she is CYP450 hepatic enzyme deficient is reviewed

• – 2D6 is markedly deficient (a poor metabolizer)

• – 2C19 is moderately deficient

Did not complete interferon treatment for hepatitis C, but is considered stable hepatically nonetheless

Family history

Denies any known psychiatric disorder in any family member

Medication history

Initial SSRI (escitalopram [Lexapro] 10 mg/d) and SNRI (desvenlafaxine [Pristiq] 50 mg/d) left her fraught with agitation and activation-based side effects

Psychotherapy history

No previous experience with psychotherapy and has relied only on PCPs for outpatient pharmacotherapy and inpatient psychiatrists as well

Somewhat receptive to the idea of attending psychotherapy as a treatment option

Patient evaluation on initial visit

Acute onset of MDD symptoms with marked agitation and insomnia roughly six months ago

She seems to be suffering immensely with guilt over her incapacity

• – This does not appear to be delusional at this time

She has been noncompliant with medication management thus far as she has developed side effects even to small doses of antidepressants and has declined psychotherapy as an option

She has apparent insight into her acute illness and wants to get better

She has current distrust of medications, and given her workup for liver metabolism enzymes, is convinced that she will get side effects on all medications