A 35-year-old man comes to the office due to weight loss and insomnia. He has been depressed about his troubled marriage and stressed by his wife's complaints about his inability to provide for the family. Lately he has had difficulty concentrating and fears that his productivity at work has fallen. The patient says, "I drag myself into work late because I can't get out of bed. Then I sit and stare at the papers piling up on my desk. I used to enjoy biking and going out with friends, but now I just come straight home from work and lie on the couch. At night, I have started having a couple of drinks to help me fall asleep." Over the past month, the patient has wished that he could go to sleep and not wake up, and has thought that he would be "better off dead." These thoughts last for several minutes when he is lying in bed awake at night. He has no intent or plan to harm himself. The patient has no history of suicide attempt or depression. There is a family history of suicide in a paternal uncle who had depression and substance abuse. The patient used cocaine and marijuana in his 20s but not in the past 8 years. He is going through a divorce and is worried that he will not get joint custody of his 2 children. Vital signs and physical examination are normal, with the exception of a 2.3-kg (5-lb) weight loss. Which of the following is the most appropriate next step in management of this patient?

Question

A 35-year-old man comes to the office due to weight loss and insomnia.  He has been depressed about his troubled marriage and stressed by his wife's complaints about his inability to provide for the family.  Lately he has had difficulty concentrating and fears that his productivity at work has fallen.  The patient says, "I drag myself into work late because I can't get out of bed.  Then I sit and stare at the papers piling up on my desk.  I used to enjoy biking and going out with friends, but now I just come straight home from work and lie on the couch.  At night, I have started having a couple of drinks to help me fall asleep."  Over the past month, the patient has wished that he could go to sleep and not wake up, and has thought that he would be "better off dead."  These thoughts last for several minutes when he is lying in bed awake at night.  He has no intent or plan to harm himself.  The patient has no history of suicide attempt or depression.  There is a family history of suicide in a paternal uncle who had depression and substance abuse.  The patient used cocaine and marijuana in his 20s but not in the past 8 years.  He is going through a divorce and is worried that he will not get joint custody of his 2 children.  Vital signs and physical examination are normal, with the exception of a 2.3-kg (5-lb) weight loss.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has classic symptoms of major depression, including depressed mood, weight loss, insomnia, impaired concentration, low energy, and decreased interest. Determining an appropriate treatment setting requires a careful assessment of suicide risk. This patient has expressed the wish to go to sleep and not awaken as well as thoughts of being "better off dead." This is sometimes referred to as "passive" as opposed to "active" suicidal ideation. The patient has no thoughts of acting to kill himself or a suicide plan. Patients with suicidal thoughts who lack a specific plan and intent can usually be treated on an outpatient basis. It is important to initiate treatment with an antidepressant and/or psychotherapy, provide close follow-up to monitor response, and perform ongoing suicide risk assessment. Hospitalization (Choice C) is usually reserved for patients who have active suicidal ideation with some intent and/or a plan, inability to care for themselves or to adhere to outpatient treatment, or complex psychiatric and medical comorbidities. (Choice A) There is insufficient justification to breach confidentiality in this case. An exception to the duty to protect patient confidentiality would be if the patient is at high, imminent risk of suicide (ie, active suicidal ideation with intent and plan to act in the near future). (Choice B) Although the patient is having several drinks at night, this is most likely an effort to self-medicate his insomnia and depression rather than a cause of his depression. The physician should counsel the patient on the negative effects of alcohol on depression, but it would be inappropriate to defer treatment of his depression. (Choice E) Suicide prevention contracts (patient promises not to act on suicidal thoughts and notify the clinician instead) are not recommended. They provide a false sense of security and have not demonstrated efficacy in decreasing the risk of suicide. Educational objective: Depressed patients with suicidal ideation but no intent or plan require aggressive treatment, but not necessarily hospitalization. References: Contracting for safety with patients: clinical practice and forensic implications. (http://www.ncbi.nlm.nih.gov/pubmed/19767501)

A 35-Year-Old Man Comes to the Office Due to Weight