A 60-Year-Old Woman Who Has Felt Sad for Much of Her Life

DR DELBANCO: A 60-year-old unemployed widow, Ms A has felt sad much of her life. She graduated from high school, has 1 child, was married twice, and used to work as an aide in health care facilities. She lives in urban housing with her mother and has public insurance. For the past 30 years she has received care from a general internist practicing in an urban primary care practice. Dating back to her first memories, Ms A recalls a troubled family life that may have included various forms of abuse. She was married and divorced in the 1970s; her daughter had some difficulty during her teens and early adulthood, but is doing well now and is close to the patient. Ms A first felt seriously depressed in her 20s. Over the years she tried alprazolam, sertraline, bupropion, diazepam, amitriptyline, nortriptyline, and citalopram, reporting that these medications calmed her down at times, but did not really affect her depression. Despite her physician’s repeated recommendations for consultation and brief attempts on her part, she has chosen generally to stay away from psychiatry and social work. She married a second time in the late 1990s, but had a disastrous relationship and returned alone to her mother’s home in 2003. There, she contemplated suicide during uncontrolled periods of crying. This led to a 3-week hospitalization for depression, during which time she learned that her husband had suddenly died. During that hospitalization, there was no evidence of psychosis or dementia. After discharge with prescriptions for 150 mg of venlafaxine and 50 mg of trazodone at night, she accepted weekly psychotherapy in a community agency for 6 months. However, she has a mechanical aortic valve and became rather casual in following directions for monitoring her warfarin levels, fell, and was hospitalized for a cranial subdural hematoma and bleeding into her perisacral region. The subdural was drained through burr holes and she recovered without medical sequelae. Thereafter, she stopped taking the antidepressants. Currently, Ms A is refusing further psychotherapy and consultation and is applying for long-term disability. She is taking clonazepam intermittently under the guidance of her internist. She has never smoked, has had only a few drinks containing alcohol, and has not used illicit drugs. Her medical history is notable for surgery for congenital aortic valvular disease in the 1970s requiring anticoagulation for her mechanical aortic valve. Over the past 30 years, she has complained often of palpitations with several evaluations yielding normal cardiac rhythm and function. She has experienced recurrent migraines, had a 6-month period of unexplained abdominal pain that cleared without specific therapy, has passed kidney stones, and is treated for mild hypertension. Currently, she is bothered primarily by impaired recent memory that appears to be exacerbated by stress. On physical examination, Ms A looks well, younger than her stated age, and has full range of affect. She smiles readily, and her internist reports not feeling sad in the room with her. She is normotensive and in sinus rhythm. Her cardiac examination is unremarkable, save for sounds produced by the prosthetic aortic valve. There is no evidence for cardiac decompensation and none for neurological deficits. Her international normalized ratio is variable, and she has low-grade chronic anemia of uncertain etiology. Her current medications include clonazepam, atenolol, triamterene, hydrochlorothiazide, clopidogrel, warfarin, calcium, and esomeprazole for symptoms of gastroesophageal reflux disease.