A 52-year-old man comes to the office because of increasing fatigue and poor concentration at work over the past month. The patient is a biology professor at a local university. He reports that he has been through a "tough year" because his 19-year-old son died of a heroin overdose 6 months ago and his book was recently rejected for publication. He sleeps 12-14 hours a day but does not feel well rested. He is frequently late for his morning office hours because it is difficult for him to get out of bed. He says, "I'm so distracted at work I forget what I've already lectured on and end up repeating myself." The patient has stopped exercising and socializing with friends, saying, "After work, all I want to do is go straight home and get back into bed." Physical examination shows no abnormalities. Mental status examination shows a tired, strained appearance and sad mood. He has no suicidal ideation. Which of the following is the most likely diagnosis?

Question

A 52-year-old man comes to the office because of increasing fatigue and poor concentration at work over the past month.  The patient is a biology professor at a local university.  He reports that he has been through a "tough year" because his 19-year-old son died of a heroin overdose 6 months ago and his book was recently rejected for publication.  He sleeps 12-14 hours a day but does not feel well rested.  He is frequently late for his morning office hours because it is difficult for him to get out of bed.  He says, "I'm so distracted at work I forget what I've already lectured on and end up repeating myself."  The patient has stopped exercising and socializing with friends, saying, "After work, all I want to do is go straight home and get back into bed."  Physical examination shows no abnormalities.  Mental status examination shows a tired, strained appearance and sad mood.  He has no suicidal ideation.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7c0_65cc_bc81_ad0fcdca487c_MD0003_00 This patient's history of sad mood, loss of interest, fatigue, hypersomnia, and impaired concentration lasting ≥2 weeks is consistent with major depressive disorder (MDD). Although his depressive symptoms were likely triggered and/or exacerbated by bereavement and professional setbacks, they are persistent, severe, and functionally impairing. MDD is the appropriate diagnosis when symptoms are sufficient in number, duration, and severity to meet diagnostic criteria. This patient should be offered treatment for MDD consisting of psychotherapy and/or antidepressant medications. (Choice A) Adjustment disorder with depressed mood is characterized by depressive symptoms that develop in response to a stressor but is not diagnosed when criteria are met for another disorder, such as MDD. (Choice C) Although depressive symptoms are common in a normal grief reaction, sadness is typically focused on the deceased and decreases in intensity over time. Although his son died 6 months ago, this patient has depression that has worsened over the past month and involves more persistent sadness and pervasive anhedonia. Excessive guilt, self-critical ruminations, and suicidality related to feelings of worthlessness and hopelessness can also help distinguish MDD from normal grief. (Choice D) Persistent complex bereavement disorder (also referred to as complicated grief) is characterized by persistent yearning for the deceased and prolonged emotional pain related to the loss, accompanied by maladaptive, ruminative thoughts and dysfunctional behaviors. (Choice E) Persistent depressive disorder is characterized by depressive symptoms lasting ≥2 years. (Choice F) Post-traumatic stress disorder is characterized by intrusive re-experiencing of a traumatic event (eg, flashbacks, intense memories), negative mood and cognitions, avoidance, and hyperarousal lasting ≥1 month. Educational objective: Major depressive disorder can be differentiated from adjustment disorders and normal grief reactions by the persistence and severity of symptoms. Pervasive sadness and anhedonia that do not decrease in severity over time should raise suspicion for major depression. References: Major depressive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/27629598) Grief, depression, and the DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/24042244)

A 52-Year-Old Man Comes to the Office Because of Increasing