Mary is a 27-year-old single woman. She has been physically disabled since birth due to spina bifida and is confined to a wheelchair. She has been a client of a primary care team since she was a toddler. She has come to see the primary care physician because of recurrent urinary tract infections. Three months ago, she moved out of her parent's house into an apartment (supported by health professionals and designed for a person with physical disabilities). The move was an important stepping stone in her life since she never thought she could be fully independent.
When Mary came to see her family doctors two months ago because of a two-day history of dysuria, hematuria, fatigue, low-grade fever, sadness and lack of motivation, the family physician came to the conclusion that the primary source of her symptoms was a urinary tract infection. The diagnosis was confirmed by urinalysis and urine culture. She was given a course of antibiotics, which cleared her symptoms; however, one week later the symptoms reappeared.
Mary returned for another course of antibiotics and was asked to follow up with the nurse after finishing. At the follow-up appointment, the primary care nurse asked her questions about her mood and how she was enjoying her new life (i.e., she was screened for depression). To the nurse's surprise, Mary stated that her mood was rather down and she did not want to leave the apartment because it was too much work and "not fun." 
Mary reported to the nurse that her mood started to decline when she moved into her new apartment. She noted that she did not tell anyone because she "did not want to give the impression of failing or being afraid." She used to be very good in managing her basic activities of daily living, including toileting, but stated that she started to neglect her basic hygiene because she felt tired and unmotivated, and did not care much about her appearance. She
"I did not want to change my wet diaper as often as I used to if I was not going to see anyone or going out." 
The nurse briefly shared the new information with the family physician, who was booked solid that day and could not see Mary for further consultation. Both decided that asking her to do a PHQ-9 (self-report questionnaire) in the waiting room would assist them in deciding if she met the criteria for depression and whether or not to involve her social worker. The social worker, who knew Mary well since she helped move her into her new apartment, reviewed the self-report PHQ-9 and got an update from the nurse about the most recent health problems. Within a few minutes of discussion between the social worker, nurse and client, a new possible explanation of the recurrent urinary tract infection was formulated: Having moved to an independent house environment was more stressful than expected. The social isolation and the energy necessary to keep up with her apartment contributed to her feeling exhausted by the end of the day. The exhaustion led to what the client called feeling "burnt out" and was associated with her reported poor energy, low motivation, neglect, depressed mood and feelings of "being a failure."
The social worker and nurse were concerned not only about the severity of Mary's depressed mood but whether she was also suicidal. Mary clearly stated that although she felt down she would never hurt herself, noting "there are so many things I want to do in life." Mary returned home with the understanding that the team was going to review options to help her. However, she stated that she did not want to take any antidepressants if that was one of the options. 
Mary met the criteria for moderate depression and was not suicidal, but she was having recurrent urinary tract infections and experiencing new stressors in her life that she was having difficulty coping with. At the end of the day, the clinical team gathered for 30 minutes to discuss difficult cases or emergencies as usual. They had a chance to review Mary's case and decided to come up with a care plan. According to best practice guidelines, Mary would benefit from an antidepressant but she did not want to take medications; Mary also needed to adapt to the stressors and maintain her activities of daily living to reduce the risk of future urinary tract infections.
The team of physician, social worker and nurse came up with a short-term plan considering Mary's preferences, which included:
  • weekly counselling sessions with the social worker, who was going to monitor Mary's depression and provide her with cognitive-behavioural therapy
  • a request for homecare to assist Mary in returning to optimum activities of daily living
  • weekly urinary tract infection screenings by the nurse
  • a psychiatrist's second opinion if depression did not improve after implementing the care plan.
The psychiatrist attended the primary care clinic twice a month and usually assessed clients with either a social worker, nurse or family physician, or as a team (depending on the severity and complexity of the case) to ensure continuity. 
After two weeks, Mary did not have any more urinary tract infection symptoms and was eating better, but she was not sleeping well, her mood was still somewhat down, and she felt too drained to go outside. In other words, there was minimum improvement of her depressive symptoms despite the additional support and counselling. She reluctantly agreed to see the psychiatrist with the social worker.
The psychiatrist's opinion confirmed the diagnosis of major depression and it was recommended that Mary start a trial of antidepressants and continue counselling sessions. Mary agreed to start medication but did not want to follow up with the psychiatrist, stating,
"It is nothing against you, doctor, but I do not want people to know that I am seeing a psychiatrist." 
She was monitored by her family doctor and social worker. Her progress was regularly discussed during monthly supervision meetings with the psychiatrist and the team.

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