Ortho/ FM Review Referral Letter

Dear Behavioral Health Team,

I am writing to refer my patient, Mr. Carter, who presented with chronic lower back pain and symptoms of depression. He reports persistent lower back pain occurring daily, which worsens in the mornings and after prolonged sitting. This pain has disrupted his sleep and appears to have a cyclical relationship with his mood, as he describes a significant decline in mood, feeling low most days, and losing interest in previously enjoyed activities. While he denies active thoughts of self-harm, he occasionally feels it would not matter if he did not wake up, expressing exhaustion and hopelessness.

My most recent assessment of Mr. Carter on February 7, 2026, revealed the following:

DIAGNOSIS:
- Other low back pain (M54.59)
- Major depressive disorder, recurrent, moderate (F33.1)

PRESENTING SYMPTOMS:
- Persistent lower back pain disrupting sleep and daily activities.
- Depressive symptoms including low mood, loss of interest, and feelings of hopelessness.

RELEVANT HISTORY:
- Lumbar spine MRI reveals mild degenerative disc disease without indications for surgical intervention.

TREATMENT TO DATE:
Mr. Carter has been prescribed a low-dose serotonin-norepinephrine reuptake inhibitor (SNRI), duloxetine, to address both his mood and nerve-related pain. He has also been advised to continue physical therapy as part of his back pain management plan. Additionally, we discussed the potential use of a short-term muscle relaxant for symptomatic relief, which will be considered based on his progress.

Given Mr. Carter's presentation and the impact of his symptoms on his quality of life, I believe he would benefit from cognitive behavioral therapy (CBT) to address his chronic pain and depression. Your expertise in this area would be invaluable in helping him manage his condition and improve his overall well-being.

Please do not hesitate to reach out if you need any additional details on Mr. Carter's case. I appreciate you taking the time to review and look forward to coordinating care.

Sincerely,

Dr. Morgan Lee