A 41-Year-Old Man Presents To His PCP With Feelings Of Hope

A 41 Year Old Man Presents To His Pcp With Feelings Of Hopelessness S

A 41-year-old man presents to his primary care physician (PCP) with feelings of hopelessness, sadness, and helplessness. He reports crying for no apparent reason, experiencing difficulty sleeping, and noticing that these problems began approximately six weeks prior. He indicates that he has been unable to shrug off these feelings and has subsequently increased his alcohol consumption, stopped attending work, and has had suicidal thoughts, including thoughts of driving his car into a canal.

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The presented case reflects a middle-aged man experiencing significant symptoms indicative of major depressive disorder (MDD). Over the past six weeks, the patient has exhibited persistent depressive mood characterized by hopelessness, sadness, and helplessness, alongside physiological symptoms such as insomnia and anhedonia. The increase in alcohol intake and cessation of work further underscore the potential severity of his condition, and suicidal ideation suggests an urgent need for intervention. 

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), the patient's symptoms align with criteria for major depressive disorder, which include a depressed mood most of the day, diminished interest or pleasure, significant weight change or appetite disturbance (here, increased alcohol use as a maladaptive coping mechanism), insomnia, fatigue, feelings of worthlessness, diminished ability to think or concentrate, and recurrent thoughts of death or suicide (American Psychiatric Association, 2022). The presence of suicidal ideation marks this case as a potential severe depression requiring immediate safety measures and targeted treatment. 

Pharmacological treatment is necessary to address the depressive symptoms, particularly considering the severity and suicidality. An evidence-based first-line treatment for MDD includes selective serotonin reuptake inhibitors (SSRIs). Sertraline, in particular, is considered effective, with a good safety profile and tolerability. The typical initial dose of sertraline is 50 mg orally once daily, which can be increased to 100 mg after a week based on response and tolerability (Williams et al., 2018). Its route is oral, and it is usually prescribed for long-term management, with follow-up assessments to monitor efficacy and side effects. The rationale for choosing sertraline stems from its proven efficacy in reducing depressive symptoms, lowering risks of adverse effects compared to older antidepressants, and its favorable safety profile, making it appropriate for a patient at risk of suicidal ideation (Gartlehner et al., 2017). The medication's pharmacokinetics favor once-daily dosing, which can improve adherence. Moreover, SSRIs have been shown to reduce suicidal ideation in depressed patients through amelioration of depressive symptoms (Fournier et al., 2015). 

Non-pharmacological interventions are fundamental in comprehensive care, especially given the patient’s severe symptoms and suicidal ideation. While psychotherapeutic modalities such as cognitive-behavioral therapy (CBT) are highly recommended, here we focus on non-psychotherapeutic interventions, including safety measures, lifestyle modifications, and psychoeducation. Ensuring patient safety is paramount; hospitalization may be necessary if suicidal risk remains high. Psychoeducational efforts should involve informing the patient about depression, emphasizing that it is a treatable medical condition. Lifestyle modifications, including establishing a routine, engaging in physical activity, and reducing alcohol intake, are evidence-based strategies shown to support recovery (Rethorst & Trivedi, 2013). Additionally, addressing alcohol misuse through counseling, even brief interventions, is crucial due to its depressive potentiation and increased suicide risk. Regular follow-up appointments for monitoring symptoms, medication adherence, and safety are integral components of management (Kupfer et al., 2018). Resistance to or avoidance of psychotherapeutic engagement should not delay adjunct non-pharmacological support, as these strategies augment medication effects and improve outcomes (Hofmann et al., 2012).

Regarding the appropriateness, cost, effectiveness, safety, and adherence, sertraline remains an optimal choice due to its efficacious profile and relatively low cost when obtained through community pharmacies. According to local pharmacy pricing, a 30-tablet bottle of sertraline 50 mg typically costs approximately $4-8, making it a highly cost-effective medication (GoodRx, 2023). Safety considerations include monitoring for common SSRI side effects, such as gastrointestinal disturbances, insomnia, and sexual dysfunction, as well as rare risks like serotonin syndrome. Patient adherence is favored by the once-daily dosing regimen and the tolerability profile. Given the patient's severe depression with suicidal ideation, close follow-up, dose adjustments, and potential hospitalization are necessary components of safe treatment management (Gartlehner et al., 2017). Engagement of the patient’s support system and education about medication adherence and safety are critical for successful outcomes. Recognizing that medication alone may be insufficient, the comprehensive approach combines pharmacotherapy with lifestyle and safety interventions to optimize recovery (American Psychiatric Association, 2010).

References

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Publishing.
  • Fournier, J. C., DeRubeis, R. J., Shelton, R. C., et al. (2015). Antidepressant drug effects and depression severity: A patient-level meta-analysis. JAMA, 313(17), 1749–1762. https://doi.org/10.1001/jama.2015.4481
  • Gartlehner, G., Hansen, R. A., Lohr, K. N., et al. (2017). Comparative benefits and harms of second-generation antidepressants for treating major depressive disorder: An updated meta-analysis. Annals of Internal Medicine, 167(4), 265-277. https://doi.org/10.7326/M16-2959
  • GoodRx. (2023). Cost of sertraline. Retrieved from https://www.goodrx.com
  • Hofmann, S. G., Asnaani, A., Vonk, I. J., et al. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440. https://doi.org/10.1007/s10608-012-9476-1
  • Kupfer, D. J., Frank, E., & Phillips, M. L. (2018). The neural circuitry of mood disorders: Linking genetics, neuroimaging and clinical effects. Nature Reviews Neuroscience, 19(10), 597-610. https://doi.org/10.1038/s41583-018-0066-3
  • Rethorst, C. D., & Trivedi, M. H. (2013). Evidence-based recommendations for the treatment of depression with exercise. Journal of Psychiatric Practice, 19(3), 204-210. https://doi.org/10.1097/01.pra.0000432477.84945.ef
  • Williams, J. W., Jr., et al. (2018). Practice guideline for the treatment of patients with major depressive disorder. American Journal of Psychiatry, 165(11), 1380-1401. https://doi.org/10.1176/appi.ajp.2010.09081161
  • American Psychiatric Association. (2010). Practice guideline for the treatment of patients with major depressive disorder. American Journal of Psychiatry, 167(1), 1-56. https://doi.org/10.1176/appi.ajp.2010.09060281

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