Case Study

C.J. is a 54-year-old man who presents with a request to refill his antihypertensive medication. He reports no problems; his blood pressure is well controlled on his current medication regimen; and his physical examination is unremarkable.

Case Study Questions

1. In which of the following situations would the U.S. Preventive Services Task Force (USPSTF) recommend that C.J. be screened for depression?

   A. He has a strong social support network of family and friends.

   B. He has access to a nurse on staff who can conduct a follow-up assessment.

   C. He has access to a local suicide prevention hotline.

   D. He has access to a clinician on staff who can provide cognitive behavior therapy.

2. As part of the depression screening, you ask C.J. two questions to evaluate mood and anhedonia: “Over the past two weeks, have you felt down, depressed, or hopeless?” and “Over the past two weeks, have you felt little interest or pleasure in doing things?” His answers indicate a disinterest in performing routine activities since losing his job seven months ago. Which one of the following is the appropriate next step?

   A. Prescribe a selective serotonin reuptake inhibitor (SSRI) and refer C.J. to a mental health professional for psychotherapy.

   B. Have C.J. return for a follow-up visit with a trained nurse specialist.

   C. Refer C.J. to a mental health professional for cognitive behavior therapy.

   D. Conduct a full diagnostic interview to determine the presence or absence of specific depressive disorders.

   E. Refer C.J. to a social worker who works in the clinic.

3. According to the USPSTF, which of the following patients are on a treatment regimen that has an increased potential for harm?

   A. A 47-year-old woman who takes paroxetine for dysthymia.

   B. A 76-year-old woman who takes fluoxetine for depression.

   C. A 19-year-old woman who takes paroxetine for depression.

   D. A 65-year-old man on a daily aspirin regimen who takes fluoxetine.

   E. A 61-year-old man who takes sertraline for seasonal affective disorder.

Answers

1. The correct answers are B and D. The USPSTF recommends that adults be screened for depression only when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. The USPSTF found good evidence that programs combining depression screening and feedback with staff-assisted depression care supports improve clinical outcomes in adults. The USPSTF recommends against routine screening for depression in adults when staff-assisted depression care supports are not in place. The USPSTF found fair evidence that screening and feedback alone, without staff-assisted care supports, do not improve clinical outcomes in adults. However, considerations, such as multiple risk factors for depression, may warrant screening in an individual patient, despite the absence of staff-assisted depression care supports.

Staff-assisted depression care supports refer to clinical staff who can assist the primary care physician by providing direct depression care, such as referral to behavior treatment, support for medication adherence, or conducting follow-up assessments. Although a strong social support network or suicide prevention hotline may be beneficial in treating certain patients with depression, they are not recognized as methods of staff-assisted depression care supports.

2. The correct answer is D. According to the USPSTF, all positive depression screening tests should trigger full diagnostic interviews that use standard diagnostic criteria to determine the presence or absence of specific depressive disorders, such as major depressive disorder or dysthymia. The severity of depression and comorbid psychological disorders (e.g., anxiety, panic attacks, substance abuse) should be addressed before referring the patient for treatment.

3. The correct answers are B, C, and D. The USPSTF found at least fair-quality evidence that second-generation antidepressants (mostly SSRIs) increase suicidal behaviors in adults 18 to 29 years of age, especially in patients who receive paroxetine and those with major depressive disorder. The USPSTF found at least fair-quality evidence that SSRI use in adults older than 70 years is associated with an increased risk of upper gastrointestinal bleeding, and this risk increases with age. In adults 40 to 79 years of age, the concurrent use of SSRIs with low-dose aspirin or a nonsteroidal anti-inflammatory drug increases the risk of upper gastrointestinal bleeding.