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
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 wouldn’t miss me that much.”
The primary care provider asks Angela to fill out a Beck’s Depression Scale, which
indicated she has moderate depression.
1. What medication would you first prescribe to this patient?
2. She comes back in 2 weeks and states she has not noticed and change in her mood since starting on the medication. What would be your response?
3. What are the possible problems with the medication you prescribed?
4. How long should you continue the treatment regimen?
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