A 39-year-old woman comes to the office due to persistent sadness since her father died suddenly 8 months ago. She is accompanied by her husband, who says, "Of course it was a shock when it happened, but I thought she would be over his death by now." The patient says, "I feel badly. I thought I would feel better by now too, but it has been a struggle." Since her father's death, the patient has been easily distracted and her work performance has declined, forcing her to take a leave of absence. She says, "Now I have more time to spend with the kids, but I find myself wanting to stay home and be by myself. I used to enjoy reading mystery novels and playing tennis, but lately these things don't interest me and I feel tired all the time." The patient sleeps reasonably well but has gained 6.8 kg (15 lb) over the past year. She has no thoughts of suicide and no history of psychiatric illness. Physical examination and routine laboratory evaluation are noncontributory. The patient requests that her husband be present to discuss the evaluation and treatment recommendations. He says, "It has been frustrating because she seems to want to be stuck in the past, and I worry about how it is affecting our marriage and children. She has been completely uninterested in sex since her father died. I don't understand why this has been going on for so long. Why can't she snap out of it?" Which of the following is the most appropriate response to the husband's concerns?

Question

A 39-year-old woman comes to the office due to persistent sadness since her father died suddenly 8 months ago.  She is accompanied by her husband, who says, "Of course it was a shock when it happened, but I thought she would be over his death by now."  The patient says, "I feel badly.  I thought I would feel better by now too, but it has been a struggle."  Since her father's death, the patient has been easily distracted and her work performance has declined, forcing her to take a leave of absence.  She says, "Now I have more time to spend with the kids, but I find myself wanting to stay home and be by myself.  I used to enjoy reading mystery novels and playing tennis, but lately these things don't interest me and I feel tired all the time."  The patient sleeps reasonably well but has gained 6.8 kg (15 lb) over the past year.  She has no thoughts of suicide and no history of psychiatric illness.  Physical examination and routine laboratory evaluation are noncontributory.  The patient requests that her husband be present to discuss the evaluation and treatment recommendations.  He says, "It has been frustrating because she seems to want to be stuck in the past, and I worry about how it is affecting our marriage and children.  She has been completely uninterested in sex since her father died.  I don't understand why this has been going on for so long.  Why can't she snap out of it?"  Which of the following is the most appropriate response to the husband's concerns?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1a6_b0aa_8f63_d57971871b8f_MD0005_00 This patient's persistently depressed mood, decreased interest, anhedonia, impaired concentration, fatigue, and appetite change leading to weight gain meet the criteria for a major depressive episode. Her symptoms have led to significant functional impairment, and treatment is indicated. The husband's frustration at her lack of improvement should be addressed by educating him about her diagnosis of major depression and the need for treatment. Differentiating normal grief from a major depressive episode is difficult as symptoms of grief often overlap with those of major depression. Grieving individuals tend to have intermittent periods of sadness that revolve around reminders of the deceased. In contrast, depressed individuals are more likely to have continuous sadness and pervasive anhedonia, and they experience greater social and occupational dysfunction. Like any other stressor, loss of a loved one can trigger a major depressive episode that should be treated. (Choices A and E) These statements would be appropriate if the patient was experiencing a normal grief reaction. Many individuals experience different stages of grief (denial, anger, bargaining, depression, and acceptance), with most returning to normal functioning by a year after the loss. However, this patient's persistent depressive symptoms are more indicative of a major depressive episode. (Choice B) Advising the patient's husband to be more supportive is unlikely to be effective as he is frustrated and believes she should be finished grieving by now. Explaining that she is experiencing a major depression that requires treatment would address his misunderstanding. (Choice C) The patient and her husband could benefit from couple's counseling to explore underlying issues in their relationship that may contribute to their current difficulties. However, educating the patient's husband about her diagnosis and the need for treatment would be the most appropriate next step. Educational objective: Persistent sadness, pervasive anhedonia, and functional impairment can help differentiate normal grief from major depressive disorder. When major depression is identified, physicians must educate patients and their families about the diagnosis and initiate appropriate treatment. References: The removal of the bereavement exclusion in the DSM-5: exploring the evidence. (http://www.ncbi.nlm.nih.gov/pubmed/24136623) The bereavement exclusion and DSM-5: an update and commentary. (http://www.ncbi.nlm.nih.gov/pubmed/25337442)

A 39-Year-Old Woman Comes to the Office Due to Persistent