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R.N. is a 44-year-old man with a primary diagnosis of right transtibial amputation secondary to trauma sustained in a motor vehicle accident. The amputation left the patient with an 8-inch residual limb distal to the knee. While in the hospital, R.N. received physical therapy, occupational therapy, and social services. He was discharged home and immediately began outpatient physical therapy for further amputation rehabilitation, including permanent prosthesis fitting and gait training. Upon initial examination, R.N. demonstrated moderate weakness in the right lower extremity with tenderness and increased sensitivity in the residual limb. He required contact guard assistance with sit-to-stand transfers and demonstrated independence with household distance ambulation with his prosthesis and a front-wheeled walker. R.N. stated that his primary limitation was significant pain in his right residual limb with all weightbearing activities. R.N. is currently unable to work in his lawn maintenance and landscaping business. He admits that this has made him very anxious and unable to sleep at night. He has occasionally been taking diazepam at night to help him sleep and tramadol to help alleviate the pain. Initial rehabilitation interventions included therapeutic exercises focused on bilateral lower extremities and pelvic and trunk musculature and progressive gait training. On several occasions, the therapist noted that R.N. complained of not being able to take a deep breath and a burning and “squeezing” feeling in his chest. Upon further questioning, R.N. stated that this happened almost every night in the early evening and occasionally during the day. He stated that he was having a hard time sleeping at night but did not like taking the diazepam because it made him feel “groggy” in the morning. With the patient’s approval, the physical therapist contacted the patient’s physician to inform her of R.N.’s major complaints.


Major depression is one of the most common forms of mental illness in the United States with as many as 5% of the population depressed at any given moment (point prevalence), and an estimated 17% of people becoming depressed during their lifetime (lifetime prevalence). The symptoms of depression can be both psychological and physiological, including intense feelings of sadness and despair, sleep disturbances (too much or too little), anorexia, fatigue, somatic complaints, and suicidal thoughts. Often, symptoms can be subtle and unrecognized by patients and healthcare professionals.

Depression is a heterogeneous disorder that has been classified as (1) “reactive” or “secondary” depression (most common) that occurs in response to situational stimuli such as grief or illness; (2) “endogenous” depression or major depressive disorder (MDD), a genetically determined biochemical disorder of depressed mood without any obvious medical or situational causes, manifested by an inability to experience ordinary pleasure or to cope with ordinary life events; and (3) depression associated with bipolar affective (manic-depressive) disorder.

Physical therapists may encounter patients taking antidepressant medications under a number of circumstances. Many patients who have experienced ...

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