Introduction: chronic medical conditions and depression--the view from primary care.

p p m t artin Hickman maneuvered his way into the office and ulled up his sleeve as the medical assistant put the brake on is wheelchair and fastened the blood pressure cuff around is oversized upper arm. A bulky 56-year-old man with a eavy shock of gray hair teetering on the edge of his orehead, his problem list included type 2 diabetes mellitus, hronic obstructive pulmonary disease, hypertension, obeity, and hyperlipidemia. For the past 15 years he had used wheelchair because of T4 paraplegia from a gunshot ound. He suffered from bouts of major depression that esponded to sertraline but never fully remitted. As the edical assistant inflated the cuff, Mr. Hickman smiled eakly and maintained a cheerful façade even after she nformed him that his blood pressure was 164/88 mm Hg nd his glucose was 267 mg/dL (14.82 mmol/L)—both well bove goal. Later, after more careful questioning by his rimary care physician, Hickman admitted that he was feelng “more down than usual” and that he sometimes nelected to take his diabetes medicine and blood pressure ills. Thinking back over the years he had cared for this atient, the physician recalled that December tended to be a articularly bad month. Social isolation, tolerable for most f the year, became painful around the holidays. December lso happened to mark the anniversary of Hickman’s spinal ord injury. he clock was running, the waiting room was full, and the hysician realized he was already falling behind. . . . [patient name is fictitious]