Questions and Topics We Can Help You To Answer:
Paper Instructions:

Topic: Depression and Anxiety
Read the following case and answer the questions using EBP.
Chief Complaint
Mary Williams is a 48-year-old African American female who presents to the clinic for her 6-week follow-up of hypothyroidism and depression therapy. At that time, she was prescribed Prozac 20mg daily for mild depressive disorder and levothyroxine 100 mcg daily for hypothyroidism. She was also diagnosed as being perimenopausal at that time based on symptoms and FSH level, but she declined HRT therapy because “I don’t want all of that stuff in my system if I don’t really need it.” Her chief complaint today is that “I still feel down in the dumps and can’t seem to get it together…the Prozac and levothyroxine are not helping.” She also verbalizes worsening “hot flashes,” and difficulty sleeping, and irritability. She denies feelings of hopelessness or suicidal ideations. She verbalizes feeling “successful in this phase of life, but just can’t shake this ‘down in the dumps’ feeling.” She denies having a menstrual cycle since her last visit.
Past Medical History
Hypertension: diagnosed age 40.
Perimenopause (stage -1) diagnosed 6 weeks ago as evidenced by: FSH >60, skipped 2-3 menstrual cycles this year and vasomotor symptoms present (ASRM, 2008).
Hypothyroidism diagnosed 6 weeks ago.
Depression diagnosed 6 weeks ago.
Medications
Diovan (valsartan 160/ HCTZ 12.5): 1 tablet daily.
Prozac 20mg daily.
Levothyroxine 100mcg daily.
Multivitamin once a day. Denies any other supplements.
Social History
Single: divorced 1 year ago and lives alone.
Occupation: retired as an elementary school teacher 7 months ago after teaching for 25 years.
Sexual habits: Denies having had intercourse or any sexual desire for intercourse or masturbation for “over a year.”
Physical Exam
Remarkable for the following:
BP: 118/72 HR: 78 Respirations: 15 Temp: 97.8 SPo2: 99% 
WT: 135 pounds; an increase from 131 pounds four weeks ago.
Skin and hair: Skin is dry, but texture has improved. Nails chipped and brittle in appearance. Hair thin, less brittle.
HEENT: Appropriate affect. Eyebrows thin. No thyroid enlargement or nodules palpated. Thyroid nontender to palpation. Speech: Normal rate and enunciation.
Musculoskeletal: No hyporeflexia or bradykinesia. Reflexes within normal limits.
Additional Disease-related History
Her initial TSH result was 11.4 and is now 0.8 mIU/mil. Her free T4 was 4.8 and is now 11.9. At her last visit her FSH >60 u/L (normal <22u/L). She scored a 13 on the Hamilton Depression Rating Scale at her initial visit, indicating a borderline mild to moderate depression. Mary’s HAMD score was fairly unchanged at 12 today.
Questions:
What symptoms are concerning to you as a practitioner?
How will you treat Mary’s complaints or address her concerns?
What education would you provide this patient regarding their diagnosis and treatment?
What treatment options are available to Mary both pharmacologic and non-pharmacologic?
For any additional or missing information, you may make up any missing data according to how you think it may have presented.
Please support all decisions with evidence via guidelines and peer-reviewed articles (a minimum of 3).