Chapter 15, Drugs Affecting Central Nervous System

Instructor Case Study: Fatigued Female

Complaint
Annual examination; fatigue
History
Angela is a 54-year-old married woman with three adult children. She has been the office
manager of a small law firm for 20 years and has enjoyed her work until this past year. She has
rheumatoid arthritis with minimal impairment that has been managed well with NSAIDs. She has
been taking conjugated estrogens for 8 years and decided to stop taking them because of her
concern of their risks without sufficient medical benefit. She has tolerated the discontinuation
without difficulty.
Assessment
At her annual medical checkup appointment, she told her primary care provider that she seemed
to be tired all the time, and she was gaining weight because she had no interest in her usual
exercise activities and had been overeating, not from appetite but out of boredom. She denied
that she and her husband have had marital difficulties beyond the ordinary and she was pleased
with the achievements of her children. She noticed that she has difficulty falling asleep at night
and awakens around 4 a.m. most mornings without her alarm and cannot go back to sleep even
though she still feels tired. She finds little joy in her life but cannot pinpoint any particular
concern. Although she denies suicidal feelings, she does not feel that there is meaning to her life:
My husband and kids would go on fine if I died and probably wouldnt miss me that much.
The primary care provider asks Angela to fill out a Becks Depression Scale, which
indicated she has moderate depression.

Initial Management Plan

The primary care provider offered Angela a prescription for an antidepressant to treat her
depression (citalopram 20 mg daily). Angela was instructed to take the medication daily and
follow-up in 6 weeks.
Follow-Up Visit
At a 6-week follow-up appointment, Angela presented with similar symptoms and said she
stopped taking her citalopram after a couple of weeks because she did not notice a difference in
how she felt and did not like the morning nausea and vertigo that she had with the citalopram.
The provider then recommended escitalopram (Lexapro) 10 mg daily and stated that it was less
likely to have those side effects. This time the provider asked that the patient return in 2 weeks
for a follow-up appointment.
Follow-Up Visit
After taking 2 weeks of escitalopram, Angela returns to the clinic for a follow-up visit. She states
she doesnt feel much different, but may be less tired. She reports that the nausea and vertigo she
experienced with citalopram has not occurred with escitalopram. At this visit, the primary care
provider spends 15 minutes discussing depression, how antidepressants work, and what can be
expected of treatment. Angela is offered a referral to a mental health counselor. Angela is
concerned about the stigma of seeing a counselor, but accepts the referral.
Ongoing Care
Four weeks after starting therapy, Angela is scheduled for a phone appointment to monitor her
progress. She continues to take the escitalopram and states she is a little better. She has made
an appointment with the mental health counselor and has been to one visit. While still skeptical
that she needs counseling, Angela admits that having someone to talk to about her stressors may

be helpful. Angela is instructed to continue to take the escitalopram and schedule a follow-up
visit in a month.
Ongoing Management
After a year of therapy, the primary care provider should evaluate Angelas depression and
consider tapering her off of selective serotonin reuptake inhibitor therapy.
Principles Demonstrated
Angelas case illustrates the importance of adequate education and close early follow-up of a
patient that is newly prescribed an antidepressant. Care should be taken when considering
whether to start an antidepressant as part of another visit, in this case her annual examination.
Time should be taken at the initial visit to thoroughly educate the patient and spend time
answering questions.
While she did not become suicidal, waiting 6 weeks for her first follow-up visit led to her
stopping the citalopram due to adverse effects without her providers knowledge. When starting
a patient on an antidepressant, he or she needs to be followed at least weekly by phone for the
first few weeks of treatment to assess for adverse effects of the medication and for suicide risk.