CASE Worsening depression
Mr. N, age 64, is a disabled factory worker with a complicated medical history. He has poorly controlled type II diabetes mellitus; obesity (body mass index 40 kg/ [m.sup.2] ); complicated cryptogenic cirrhosis with prior esophageal varices, portal gastropathy, splenomegaly, and no encephalopathy; surgically treated colon adenocarcinoma; and bilateral thalamic and right occipital infarcts with residual left homonymous hemianopsia and vertical gaze paresis. Mr. N sustained a perioperative stroke 18 months ago while undergoing a colectomy procedure for colon adenocarcinoma; an MRI done at that time showed the bilateral thalamic and right occipital infarcts. While in the internal medicine consultation clinic, Mr. N expresses suicidal and homicidal thoughts, which prompted the internal medicine team to refer him to the emergency department (ED). The team deems Mr. N's medical problems stable except for diabetic dyscontrol.
In the ED, Mr. N says he feels sad, worthless, and "tired" of his complex family issues and multiple medical conditions. He says he's had these feeling for at least a year, but his depression has worsened in the last few days. Mr. N is tearful while explaining his discouragement with following a diet for diabetes; earlier that day he ate an entire chocolate cake. He says all 3 of his children have ongoing substance abuse and relationship problems, but he is particularly focused on his youngest daughter, who is involved with a man who is addicted to drugs and physically abuses her and her children. Mr. N describes a detailed plan to shoot him and then commit suicide. This disclosure prompts the ED physician to admit Mr. N to ensure his safety and stabilize his mood.
Mr. N's temperature is 36.4 [degrees] C (97.5 [degrees] F), blood pressure is 123/60 mm Hg, pulse is 81 beats per minute, respiratory rate is 24 breaths per minute, and oxygen saturation is 96% on ambient air. His physical exam is notable only for dysphoria and mild gynecomastia. He shows no evidence of acute cardiopulmonary, gastrointestinal, or other neurologic changes. His serum glucose is 650 mg/dL, and his recent hemoglobin [A.sub.lc] (Hb [A.sub.lc] ) is 10.9%. His other laboratory tests include a hemoglobin of 117 g/dL; white cell count, 3500/ [mm.sup.3]; platelet count, 41,000/ [mm.sup.3]; sodium, 129 mEq/L; potassium, 5.0 mEq/L; alkaline phosphatase, 90 U/L; aspartate aminotransferase, 23 U/L; alanine aminotransferase, 21 U/L; total bilirubin, 1.8 mg/dL; creatinine, 1.2 mg/dL; prothrombin time, 10.4 sec; and arterial ammonia, Less than 50 [micro] g/dL. Arterial blood gases are normal.
A year ago, his primary care physician prescribed fluoxetine, 20 mg/d, for fatigue and chronic back pain and neuropathic pain related to diabetes. We continue Mr. N's outpatient prescription of fluoxetine, 20 mg/d, and low-dose acetaminophen as needed for pain. Furosemide, 40 mg/d, spironolactone, 100 mg/d, and propranolol sustained release, 60 mg/d, are maintained for complications of cirrhosis. Insulin aspart, 22 units with breakfast, 24 units with lunch, and 24 units with supper, also are administered routinely.
We consult with the internal medicine, ophthalmology, neurology, endocrinology, and diabetes services to assist in evaluating and managing Mr. N's multiple medical conditions.
Which condition would you consider as part of the differential diagnosis?
a) depression due to a general medical condition
b) adjustment disorder with disturbance of conduct
c) major depressive disorder, single episode
d) post-stroke depression
e) severe decompensation of an underlying personality disorder
The authors' observations
Depression and other forms of psychopathology may be underrecognized in geriatric patients because older adults may not report psychiatric symptoms that are secondary to physical conditions. Cognitive impairment in some older adults also may lead to underreporting of symptoms. …