Patient A is a white woman, 68 years of age, with a 15-year history of type 2 diabetes. She presents to her primary care provider for a three-month follow-up appointment. She is brought to the appointment by her daughter-in-law. She is 5 feet 4 inches tall and weighs 220 pounds, 10 more pounds than her last appointment. Other pertinent medical history includes hypertension, coronary artery disease, two transient ischemic attacks lasting 30 minutes each, cerebrovascular accident nine months previously resulting in right-side weakness, and peripheral neuropathy of the bilateral lower extremities.

Her vital signs are:

Blood is drawn, and the results indicate:

During the visit, Patient A sits quietly and only answers questions with yes or no. When asked if she has ever received formal education to care for her diabetes, Patient A states she did when she was first diagnosed, but it was many years ago. Understanding that Patient A now qualifies to receive education for diabetes self-management under Medicare, the need for further education is discussed with the patient and her daughter-in-law. They agree, although the daughter-in-law is reluctant to participate. The primary care provider refers Patient A to an ADA-recognized education program.

Patient A's initial education appointment is delayed three weeks due to conflicts with her daughter-in-law's schedule. They arrive at the education center five minutes late. When Patient A attempts to apologize for their tardiness, her daughter-in-law snaps at her to just sit down. Patient A takes a seat and begins reading a magazine. During the assessment phase of the visit, the diabetes educator, Ms. R, asks Patient A about her support system and finds that Patient A started living with her son and daughter-in-law after the death of her husband one year ago in a car accident. The move had been a decision out of necessity. Patient A's daughter-in-law receives a telephone call and leaves the room to take it.

While the daughter-in-law is out of the room, Ms. R asks Patient A about her home life. Patient A indicates that it has been a struggle to adapt to her new life. When asked about her daily routine, Patient A states she gets up in the morning and attempts to make breakfast, but it usually takes too long, which causes her daughter-in-law to get impatient and take over. When asked what she likes to do during the day, Patient A replies, "Nothing." Ms. R asks what she liked to do prior to living with her son's family. Patient A states she liked her monthly lunches with a prayer group from church and that she misses them. Patient A also recalls date nights she used to have with her husband. In addition, the couple would attend Mass every Sunday and go out to brunch with good friends afterward.

At the conclusion of the appointment, Ms. R inquires whether Patient A has anything to add. Patient A states, "What's the use? I just exist now anyway. I am so mad at my husband for leaving me here. I was supposed to go first." When Ms. R asks how long she has felt this way, she admits it has been difficult since the death of her husband, but it has been worse the past two months. Patient A states she has been sad or depressed most of the time over the past two weeks.

The daughter-in-law returns and inquires if there is anything else or if they can leave, having already made the next appointment to fit her schedule. Ms. R reassures Patient A that she will see her at the next visit. After the patient leaves, Ms. R documents the visit and calls Patient A's primary care provider to communicate her concerns that she is experiencing depression.

Patient A's physician calls and requests an appointment for the next week. Although her daughter-in-law is unhappy about the additional appointment, she agrees to drive the patient to the office.

The patient arrives to see her physician and is taken into a room; the daughter-in-law is asked to stay in the waiting room. When the physician enters, he asks Patient A about her week. Patient A only shrugs her shoulders and avoids eye contact. The physician states that he is worried about her and thinks talking to someone might help. Patient A indicates that she talks to her son when he has time, but lately he has been working long hours. The only other conversation she reports is with the nurse at the education center. The physician tells the patient that Ms. R is concerned about her as well. Due to the many changes and stressors of the past year, the physician recommends that she see a mental health professional so she can talk to someone outside her immediate family.

The daughter-in-law is then asked to join them in the examination room, where she listens to the physician's concerns and referral plan. She unenthusiastically agrees to assist Patient A attend psychiatry appointments.

Later that week, Patient A meets with Dr. M, a psychiatrist specializing in major depression. She attends the session with her son, who appears attentive and concerned about his mother. Patient A is able to verbalize her feelings and fears during the session, but she continues to experience unrelenting sadness and fatigue. So, an antidepressant is prescribed to improve her mood. Dr. M also suggests a family session involving Patient A's daughter-in-law in order to address issues in the family dynamic.

Six months later, Patient A returns to her primary care provider, who notes many improvements. Patient A is going to church regularly and has joined a prayer group and met two other women who are also widows. They now go out to dinner regularly. Her demeanor is improved, and she is engaged and more confident. The patient also reports having more energy and a better relationship with her daughter-in-law. To monitor her diabetes, blood is drawn, and the laboratory results indicate decreases in her HgA1c (7.2%) and random blood glucose (145 mg/dL).