A 19-year-old man with mild intellectual disability is brought to the office by his mother for a follow-up visit. The patient has worked at the post office for more than a year without difficulty, but his supervisor recently expressed concern about poor performance and a change in behavior. The mother says that the patient has been somewhat sad and nervous around the house lately but has no difficulty with sleep or appetite. The patient continues to go to work and spend time with his family, although he is not as interactive as usual. He avoids eye contact during the interview and appears anxious. When asked questions directly, the patient responds mostly with single-word answers, a departure from his usual friendly and talkative demeanor. The mother says, "He seems like he's depressed. He'd probably feel better if he started on an antidepressant." Which of the following is the most appropriate next step in management?

Question

A 19-year-old man with mild intellectual disability is brought to the office by his mother for a follow-up visit.  The patient has worked at the post office for more than a year without difficulty, but his supervisor recently expressed concern about poor performance and a change in behavior.  The mother says that the patient has been somewhat sad and nervous around the house lately but has no difficulty with sleep or appetite.  The patient continues to go to work and spend time with his family, although he is not as interactive as usual.  He avoids eye contact during the interview and appears anxious.  When asked questions directly, the patient responds mostly with single-word answers, a departure from his usual friendly and talkative demeanor.  The mother says, "He seems like he's depressed.  He'd probably feel better if he started on an antidepressant."  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

When patients have difficulty providing history themselves, obtaining collateral information from family members is important. However, all patients-including vulnerable adults, children, and the elderly-should be given the opportunity to speak with their physicians alone and tell their stories in their own words. Although the mother's assessment that her son is depressed may be accurate, other factors may be causing or contributing to the patient's recent change in behavior and reluctance to speak. When children or patients with intellectual impairments do not answer questions directly, it should not be assumed that they are unable or unwilling to do so. They may feel uncomfortable answering certain questions in front of their family members. This is especially true of questions regarding mental health (including suicidal thoughts), drug use, sexual history, and domestic violence. Allowing this patient the opportunity to talk to the physician alone may help clarify his concerns, develop rapport, and establish a more effective treatment plan. (Choice A) Asking the mother about her concerns regarding the patient's work environment in front of the patient may cause embarrassment and damage rapport. The patient should be interviewed privately and given an opportunity to discuss any concerns he may have about work without his mother present. (Choice B) Discussing antidepressant medication should not precede conducting an evaluation of the patient's concerns and mental status in a private setting. (Choice D) The patient may feel pressured to agree with his mother if she remains in the room. This patient's anxiety and limited responses suggest that he is uncomfortable. It would be best to interview him without the mother present. (Choice E) Although a depression rating scale can provide meaningful information, it may fail to identify important non-depression-related factors and is not a substitute for interviewing the patient directly. Self-reported scales may also be subject to bias; the patient might downplay his symptoms or feel pressured to agree with his mother's assessments. Educational objective: Patients may be reluctant to discuss sensitive issues in the presence of family members. All patients of all ages and functional levels should be given the opportunity to meet with their physicians alone. References: Approach to caring for developmentally disabled adults in the community: medical, ethical, and legal considerations. (http://www.ncbi.nlm.nih.gov/pubmed/25609519) Adults with developmental disabilities: a comprehensive approach to medical care. (http://www.ncbi.nlm.nih.gov/pubmed/29763271)

A 19-Year-Old Man with Mild Intellectual Disability Is Brought to the Office