# Clinical Cases: Mental Health in Primary Care ## Case 1: Major Depressive Disorder ### Patient Demographics - **Age:** 42 years old - **Sex:** Female - **Occupation:** Accountant ### Chief Complaint "I've been feeling down and have no energy. I can't seem to enjoy anything anymore." ### History of Present Illness Ms. Sarah Mitchell is a 42-year-old woman presenting with depressed mood and fatigue for the past 3 months. She reports persistent sadness "almost every day," loss of interest in activities she previously enjoyed (reading, spending time with friends), fatigue despite adequate sleep, difficulty concentrating at work, and feeling "worthless." She has gained 12 pounds over 3 months due to "eating for comfort." She reports initial insomnia (difficulty falling asleep) and early morning awakening. She denies suicidal ideation, stating "I would never do that to my kids." The symptoms began insidiously after her divorce was finalized 4 months ago. She has two children (ages 10 and 14) who live with her. She is managing work but feels she is "just going through the motions." ### Past Medical History - Hypothyroidism on levothyroxine - Migraine headaches - Prior episode of depression 8 years ago, treated with sertraline for 1 year, resolved ### Family History - Mother: Depression, anxiety - Father: Alcohol use disorder - Maternal aunt: Bipolar disorder ### Social History - Non-smoker - Occasional wine (1-2 glasses on weekends) - Recently divorced, single mother of two - Limited social support (moved to new city 2 years ago) - No current exercise (previously walked regularly) ### Mental Status Examination - **Appearance:** Appropriately dressed, appears fatigued - **Behavior:** Cooperative, psychomotor slowing noted - **Speech:** Normal rate, soft volume - **Mood:** "Sad" (patient's words) - **Affect:** Constricted, tearful at times - **Thought process:** Linear, goal-directed - **Thought content:** No suicidal or homicidal ideation, no delusions - **Perception:** No hallucinations - **Cognition:** Alert, oriented x4, concentration mildly impaired - **Insight/Judgment:** Good ### Screening Tools - **PHQ-9 Score:** 18 (moderately severe depression) - Little interest: 3 - Feeling down: 3 - Sleep problems: 2 - Tired/no energy: 3 - Appetite changes: 2 - Feeling bad about self: 2 - Trouble concentrating: 2 - Psychomotor changes: 1 - Suicidal thoughts: 0 - **GAD-7:** 8 (mild anxiety) ### Clinical Image ![Doctor-patient consultation](case_01_image.jpg) *Image: A healthcare provider engaging in a patient consultation, demonstrating the therapeutic relationship essential to primary care management of mental health conditions including depression.* **Image Source:** Wikimedia Commons **Attribution:** National Cancer Institute, Public Domain **URL:** https://commons.wikimedia.org/wiki/File:Doctor_and_patient.jpg ### Outpatient Workup - TSH: Normal (1.8 mIU/L) - rules out hypothyroidism contribution - CBC: Normal - Complete metabolic panel: Normal - Vitamin B12 and folate: Normal ### Assessment and Diagnosis 1. **Major depressive disorder, recurrent episode, moderate** - Meets DSM-5 criteria (depressed mood, anhedonia, fatigue, concentration difficulty, worthlessness, weight gain, sleep disturbance for >2 weeks) 2. **Mild generalized anxiety symptoms** - Common comorbidity 3. **Situational stressor: Divorce** - Contributing factor but symptoms meet criteria for MDD ### Management Plan **Psychotherapy:** - Referral to therapist for cognitive-behavioral therapy (CBT) or interpersonal therapy - Both evidence-based for moderate depression - Can be combined with medication for better outcomes **Pharmacotherapy:** - Given prior positive response to sertraline, restart sertraline - Sertraline 50 mg daily, may increase to 100 mg after 2-4 weeks if tolerated - Discuss: - Takes 2-4 weeks to see initial effect, 6-8 weeks for full effect - Common side effects: GI upset, headache, sexual dysfunction - Not habit-forming - Plan for at least 6-12 months of treatment after remission to prevent relapse **Lifestyle Recommendations:** - Regular exercise: 30 minutes most days (equivalent efficacy to antidepressants for mild-moderate depression) - Sleep hygiene: Regular sleep schedule, limit screen time before bed - Social connection: Encourage reaching out to friends/family - Reduce alcohol (can worsen depression) **Safety Planning:** - Direct questioning about suicidal ideation (she denies) - Provide crisis hotline number: 988 (Suicide and Crisis Lifeline) - Discuss warning signs to watch for - Involve family support if appropriate ### Follow-Up - Phone check in 1-2 weeks to assess medication tolerance - Return visit in 4 weeks to assess response (repeat PHQ-9) - Earlier if symptoms worsen or suicidal thoughts develop - Target PHQ-9 <5 (remission) ### Teaching Points 1. **PHQ-9 for depression screening and monitoring:** - 0-4: Minimal depression - 5-9: Mild depression - 10-14: Moderate depression - 15-19: Moderately severe depression - 20-27: Severe depression - Item 9 asks specifically about suicidal ideation 2. **DSM-5 criteria for MDD:** ≥5 symptoms for ≥2 weeks, including depressed mood OR anhedonia. (SIG E CAPS: Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidal ideation) 3. **Treatment approach by severity:** - Mild: Psychotherapy alone may be sufficient; watchful waiting acceptable - Moderate: Pharmacotherapy and/or psychotherapy - Severe: Combination therapy (medication + psychotherapy), consider psychiatry referral 4. **SSRI selection:** SSRIs are first-line for MDD. Choice based on prior response, side effect profile, drug interactions. Sertraline and escitalopram have favorable tolerability. --- ## Case 2: Opioid Use Disorder in Primary Care ### Patient Demographics - **Age:** 34 years old - **Sex:** Male - **Occupation:** Unemployed (former construction worker) ### Chief Complaint "I need help. I'm addicted to pills and I want to stop before I lose everything." ### History of Present Illness Mr. James Turner is a 34-year-old man presenting seeking help for opioid addiction. He reports taking oxycodone for the past 3 years, initially prescribed for a work-related back injury. Over time, his tolerance increased, he started taking more than prescribed, and he has been buying pills "on the street" for the past year after his prescriptions were discontinued. He is currently using 120-180 mg of oxycodone equivalents daily. He has tried to quit on his own several times but develops severe withdrawal symptoms (nausea, diarrhea, muscle aches, anxiety) within 12 hours. He recently lost his job and his wife has threatened to leave with their two children if he doesn't get help. He has never used heroin or injected drugs. His last use was 8 hours ago, and he is beginning to feel early withdrawal symptoms. ### Past Medical History - Chronic low back pain (work injury 3 years ago) - No surgeries - No psychiatric history ### Family History - Father: Alcohol use disorder - Mother: Anxiety ### Social History - Smokes 1 pack/day - No alcohol (stopped when opioid use increased) - Married, two children (ages 5 and 7) - Unemployed x 2 months - Previously worked in construction - High school education ### Physical Examination - **Vital Signs:** BP 138/88 mmHg, HR 92, Temp 98.8F, RR 18 - **General:** Anxious-appearing, diaphoretic, restless - **HEENT:** Pupils 4mm reactive (early dilation), rhinorrhea, lacrimation - **Cardiovascular:** Tachycardic, regular - **Abdomen:** Hyperactive bowel sounds, no tenderness - **Extremities:** No track marks, no edema - **Skin:** Piloerection (goosebumps), diaphoresis - **Neuro:** Alert, oriented, tremulous ### Assessment with COWS Score - **Clinical Opiate Withdrawal Scale (COWS):** 16 (moderate withdrawal) - Resting pulse: 2 (89-100) - Sweating: 2 - Restlessness: 2 - Pupil size: 2 (moderately dilated) - Bone/joint aches: 2 - Runny nose/tearing: 2 - GI upset: 2 - Tremor: 1 - Yawning: 1 - Anxiety/irritability: 0 - Gooseflesh: 0 ### Assessment and Diagnosis 1. **Opioid use disorder, moderate-severe** - Meets DSM-5 criteria (tolerance, withdrawal, loss of control, continued use despite consequences, craving) 2. **Opioid withdrawal, moderate** - COWS 16 3. **Chronic low back pain** - Underlying condition, needs non-opioid management ### Management Plan **Medication for Opioid Use Disorder (MOUD):** *Buprenorphine/naloxone (Suboxone) Initiation:* - Office-based initiation protocol - Wait until COWS ≥12 (moderate withdrawal) before first dose - Start buprenorphine/naloxone 4mg/1mg sublingual - May repeat 4mg/1mg in 1-2 hours if withdrawal persists - Target dose Day 1: 8-16 mg buprenorphine - Titrate to 16-24 mg daily over first week for maintenance - Prescriber must have X-waiver (note: as of 2023, X-waiver requirement removed) *Alternative Options Discussed:* - Methadone: Requires licensed opioid treatment program (OTP), daily dosing initially - Naltrexone: Extended-release injection, requires 7-14 days opioid-free first **Adjunctive Medications for Withdrawal Symptoms:** - Clonidine 0.1 mg every 6 hours PRN for autonomic symptoms - Ondansetron 4 mg every 8 hours PRN for nausea - Loperamide 2 mg PRN for diarrhea - Ibuprofen 600 mg every 8 hours for muscle aches **Behavioral Support:** - Referral to addiction counselor - Recommend 12-step program (Narcotics Anonymous) or SMART Recovery - Family counseling offered - Discuss relationship between sobriety and keeping family together **Harm Reduction:** - Naloxone (Narcan) nasal spray prescribed for home - Educate patient and wife on overdose reversal - Discuss fentanyl contamination risk in street drugs **Pain Management:** - Physical therapy referral for back pain - Non-opioid alternatives: NSAIDs, acetaminophen, duloxetine - Buprenorphine provides some analgesia ### Follow-Up - Return in 24-48 hours for dose adjustment - Weekly visits during induction phase (first month) - Monthly visits once stable - Urine drug testing at each visit - Long-term MOUD recommended (years, potentially lifelong) ### Teaching Points 1. **DSM-5 criteria for OUD:** Problematic opioid use with ≥2 criteria in 12 months (tolerance, withdrawal, larger amounts, inability to cut down, time spent obtaining/using/recovering, craving, failure to fulfill obligations, social problems, hazardous use, continued use despite problems, giving up activities). 2. **MOUD is first-line treatment:** Buprenorphine, methadone, and naltrexone all reduce mortality, overdose, and illicit opioid use. Medication alone is more effective than behavioral treatment alone. 3. **Buprenorphine in primary care:** - Partial opioid agonist with ceiling effect (safer in overdose) - Can be prescribed in office setting - X-waiver no longer required (as of December 2022) - Start when in moderate withdrawal (COWS ≥12) to avoid precipitated withdrawal 4. **Harm reduction:** Naloxone should be prescribed to all patients with OUD. Every minute without naloxone in an overdose increases mortality risk. 5. **Long-term perspective:** OUD is a chronic disease. Relapse is common and does not indicate treatment failure. Long-term MOUD is more effective than short-term tapering.