Patient evaluation on intake

57-year-old man with a chief complaint of “horrible depression”

Feels he “made a bad decision” late in his career and is now unemployed after many successful years in equipment sales

Fearful and nervous that, at his age, he is too young to retire and too old to find a new job and be successful again

Psychiatric history

He had been without major mental health issues until he left his gainful employment of 25 years as an equipment salesman

• – He left during poor corporate economic times assuming his company would fold

• – He left for a second company for a sales position in a different market, and performed poorly on commission and was let go

• – Psychiatric symptoms developed after this

Has not been able to go back to work at all due to anxiety and fear about failing again

He admits to full syndromal depressive symptoms

• – He has passive suicidal thoughts and ideational guilt that he is a bad spouse in that he has let his family down by being unsuccessful and unemployed

• – Additionally, he is amotivated, fatigued, and states he is hopeless and pessimistic about the future

He now worries about everything, all the time, cannot focus, and is tense. He states he was never like this before

Additionally, he can barely “look people in the eye” and talk to them

• – He is very concerned about doing and saying the right thing

• – After years of remembering many details in sales, he can barely keep any facts straight, and is convinced that he will fail

• – Panic attacks have occurred at recent job interviews, and since then is avoiding most situations where he has to speak to superiors

He has relatively few friends as most were colleagues at his previous job

While he is at home more, he is experiencing more conflict with his wife, although states she is supportive

Social and personal history

He graduated high school and served successfully in the military without traumatic experience

He was gainfully employed in sales for many years before changing jobs as noted

His wife is employed now but they are having difficulties financially

He does not use drugs or alcohol

Medical history

He has experienced 10 lbs of weight loss while depressed over last several months and is slightly underweight

He has no acute or chronic medical issues

He has no liver or renal disease

Family history

Denies any known psychiatric illness in any family member

Medication history

One treatment so far while in the care of his PCP

• – He failed to respond to SSRI, paroxetine (Paxil) 40 mg/d

• – Currently, perhaps 10% improvement in intensity and duration of symptoms at most because he feels less sad and weepy, but is still socially not functioning well

Psychotherapy history

Recently, started outpatient CBT with an adept clinician in the local area

Little to no response to these psychotherapeutic interventions, but acknowledges it is early in the course of this intervention and feels comfortable conversing about his problems

Patient evaluation on initial visit

Acute onset of MDD symptoms with associated, or possibly comorbid anxiety disorder roughly six months ago

Suffers immensely with guilt over his decision to leave his successful job for a new job this late in his career

Very compliant with medication management and has started psychotherapy

Good insight into his illness and wants to get better

He has current, fleeting passive suicidal ideation

There is possible guilt-based delusions (current ideation noted) but no other signs of psychosis

Reports no current side effects