A 27-year-old woman comes to the office due to headaches and neck and back pain. She has been coping with pain symptoms for several years but notes that they have increased since she was recently let go from her job as an administrative assistant. The patient worries about finding another job but says, "Most days I am just too tired to even look for work." She is also concerned about gaining weight but has no motivation to go to the gym or leave the house. The patient has been to the office twice in the past year for similar symptoms and is worried that something is wrong. At her last visit 4 months ago, laboratory testing, including a basic chemistry panel, thyroid function tests, and complete blood count, were within normal range. The patient says, "I doubt that anything will ever improve for me." Medications include ibuprofen for pain as needed. The patient drinks 1 or 2 glasses of wine 3 times a week. She has increased her use of marijuana to 3 or 4 times a week at bedtime to help her relax and fall asleep and has started smoking cigarettes after a 2-year abstinence. Family history includes hypertension and colon cancer in her father and hypothyroidism and anxiety in her mother. Vital signs and physical examination are normal except for a 2.27-kg (5-lb) weight gain since her last visit. Which of the following is the most appropriate next step in management of this patient?

Question

A 27-year-old woman comes to the office due to headaches and neck and back pain.  She has been coping with pain symptoms for several years but notes that they have increased since she was recently let go from her job as an administrative assistant.  The patient worries about finding another job but says, "Most days I am just too tired to even look for work."  She is also concerned about gaining weight but has no motivation to go to the gym or leave the house.  The patient has been to the office twice in the past year for similar symptoms and is worried that something is wrong.  At her last visit 4 months ago, laboratory testing, including a basic chemistry panel, thyroid function tests, and complete blood count, were within normal range.  The patient says, "I doubt that anything will ever improve for me."  Medications include ibuprofen for pain as needed.  The patient drinks 1 or 2 glasses of wine 3 times a week.  She has increased her use of marijuana to 3 or 4 times a week at bedtime to help her relax and fall asleep and has started smoking cigarettes after a 2-year abstinence.  Family history includes hypertension and colon cancer in her father and hypothyroidism and anxiety in her mother.  Vital signs and physical examination are normal except for a 2.27-kg (5-lb) weight gain since her last visit.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient has several findings concerning for depression, including hopelessness (doubts that anything will improve), amotivation, low energy, and weight gain. Patients with depression frequently have a somatic presentation (eg, headaches, neck and back pain) and may have difficulty describing their emotions. Further assessment of depression, including a careful screen for suicidal ideation, is the most appropriate next step in this patient's evaluation, particularly given her multiple risk factors for suicide (eg, chronic pain, recent job loss, self-medication with substances, isolation). Inquiring about suicidality allows for the determination of an appropriate and safe treatment setting (eg, hospitalization if the patient is actively suicidal). This patient should be asked if she has wished for death or has thought of killing herself. If the answer is "yes," additional questions should be asked regarding methods, plan, and intent to act on a plan. (Choices A, B, and C) Although exploring the relationship of substance use and stress to the patient's symptoms and performing a more detailed pain assessment are components of a comprehensive evaluation, inquiring about suicidal thoughts takes precedence. (Choice E) In light of this patient's recent laboratory results and the absence of new physical findings, repeat laboratory testing is unlikely to be helpful. Her weight gain is likely due to depression and lack of exercise rather than thyroid disease. (Choice F) Reassurance that serious illness has been ruled out with regular follow-up office visits is an appropriate intervention for somatic symptom disorder. However, this would not substitute for evaluation of suicidality in this patient with findings concerning for depression. Educational objective: In the primary care setting, patients with depression often have somatic symptoms. Any patient who reports feeling hopeless, even if the initial symptoms are somatic, should be screened for suicidal ideation. References: Screening for suicidal ideation and attempts among emergency department medical patients: instrument and results from the Psychiatric Emergency Research Collaboration. (http://www.ncbi.nlm.nih.gov/pubmed/23413776) Suicide interventions in primary care: a selective review of the evidence. (http://www.ncbi.nlm.nih.gov/pubmed/29809038) Primary care assessment of patients at risk for suicide. (http://www.ncbi.nlm.nih.gov/pubmed/26556217)

A 27-Year-Old Woman Comes to the Office Due to Headaches