Difficulty sleeping and fatigue
Author and Disclosure Information [Show]

Claudia Reardon, MD, Professor, Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Claudia Reardon, MD, has disclosed no relevant financial relationships.

Question 1 of 3

A 32-year-old man presents to his psychiatrist for routine follow-up, reporting very little change to his overall symptoms. One year ago, he was diagnosed with a major depressive episode after he lost his job and was unemployed for an extended period during the COVID-19 pandemic. He has since been struggling financially and remains underemployed. He was originally prescribed citalopram 20 mg orally once a day (PO QD), which after 1 month was titrated up to 40 mg PO QD. He remained at this dose for 3 months and experienced very little remission of symptoms, despite medication adherence and participating in weekly cognitive-behavioral therapy sessions. He was then switched to venlafaxine extended-release 75 mg PO QD, which after 2 months was titrated up to 112.5 mg PO QD, and later 150 mg, and then 225 mg PO QD, which is his dosage today.

Physical examination reveals nothing remarkable. The patient appears pale and fatigued but otherwise normal and well groomed. He has a flattened affect, but his speech is normal. He reports difficulty sleeping and concentrating at work and has little interest in outside activities. He describes feeling like he is "living in a fog."

His case is reviewed to verify accuracy of diagnosis and adequate medication dosing and duration, as well as to confirm adherence. He continues to participate in weekly therapy sessions.

What is the next step in the diagnostic process?

Brain MRI/CT

Depression screening test


Laboratory studies to rule out general medical causes of symptoms

This quiz is not accredited for CME.

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