Patient evaluation on intake

52-year-old man cannot sleep

He has been “in a funk” for about a year after he had difficulty at his work site

Psychiatric history

The patient has been emotionally well his whole life

About a year ago, developed vision problems due to diabetes, which interfered with his ability to work safely at his job site as an assembly line worker

He was placed on lighter duty and then ultimately laid off due to bad economic times

At the time of his transition to light duty, he began experiencing psychiatric symptoms as follows

• – Insomnia

• – Dysphoria and irritability

• – Increasing anhedonia

• – Poor concentration

• – Poor appetite

• – Feelings of worthlessness and hopelessness

• – Fatigue

• – He denied suicidal thoughts, or psychotic, manic, anxiety, and substance misuse symptoms

Social and personal history

Married with five adult children

Takes care of his grandchildren often and might be considered a primary caregiver

Has tenth grade education

Gainfully employed as an assembly line worker for many years until recently

Most of his friends, support, and identity as an autoworker were disrupted when he was forced to leave work

He does not abuse substances, nicotine, or caffeine

Medical history

Suffers from DM2 with worsening vision, renal function, and neuropathy in his feet

Has HTN and hyperlipidemia

He has good attendance and follow-up with his PCP and currently has these metabolic disorders well controlled

Family history

One son has bipolar disorder and substance abuse problems

Mother suffered from MDD

AUD is present in multiple family members at each generation

Medication history

PCP started him on the SSRI sertraline (Zoloft) 50 mg/d three weeks ago

• – Sleep is starting to improve somewhat and there is less noticeable irritability

• – Complains now that his hands feel “greasy and tacky”

  • Feels like he has residual car “motor oil on them” all the time

  • Washes his hands to no avail

  • There are no rashes or skin changes on examination

Psychotherapy history

Started supportive psychotherapy several weeks ago

Attendance is good

Feels better after sessions but this is short lived

Patient evaluation on initial visit

Patient suffers from new-onset MDD

He is somewhat better but dislikes the side effects in his hands as they “feel greasy”

Current medications

Sertraline (Zoloft) 50 mg/d (SSRI)

Insulin sliding scale

Atorvastatin (Lipitor) 40 mg/d

Metoprolol (Toprol-XL) 100 mg/d

Metformin (Glucophage) 2000 mg/d

Question

Greasy hands? Is that a real side effect?

No, it is hypochondriacal, hysterical, or a nocebo side effect

No, it is not listed in the regulatory package insert for sertraline

Yes, a web search reveals that two to three other patients have posted similar experiences

Yes, it is likely a paresthesia, and these occur in 1% of patients taking sertraline

Yes, it is a side effect because the patient says it is, and it bothers him

Attending physician’s mental notes: initial evaluation

This patient has an index episode of MDD that is moderate in severity

This was likely initiated due to an interpersonal loss and social stressor when his working career ended beyond his control

He may be starting to respond to his inaugural SSRI at this time, but has a strange side effect where his hands feel greasy, or as if they were immersed in liquid

He does not appear to have any comorbid psychiatric conditions

He has some chronic medical problems but they appear stable and well controlled

He is not felt to be suicidal