Major Depressive Disorder

A 50-year-old female presents on therapist referral for pharmacotherapy re-evaluation of longstanding, treatment-resistant depression dating to adolescence, with multiple failed antidepressant trials. Her course has been severely complicated by forced career loss (disabling migraines), a multiple myeloma diagnosis two years ago, painful surgeries/rehab, loss of independence, and relocation to her ill mother's home. She is currently on fentanyl 50 mcg daily, duloxetine, and clonazepam, but remains symptomatic with depressed mood, worthlessness, guilt, low energy, poor appetite/sleep, weight loss (likely chemo-related), and new-onset generalized worry since her cancer diagnosis. No history of mania or hypomania.