Identification: The 69-Year-Old Widowed African Patient ✓ Solved

Identification The Patient Is A 69 Year Old Widowed African

Identification The Patient Is A 69 Year Old Widowed African American male who is the father of one adult child and grandfather of six. The patient is self-referred to a psychiatric outpatient clinic. CHIEF COMPLAINT: “I need help with depression and anxiety.”

HISTORY OF PRESENT ILLNESS: The patient reports that his father is dying, and he has been experiencing worsening of depression and anxiety symptoms over the past few months. He is seeking a psychiatric evaluation at his son’s advice. The patient does not enjoy being with his family. He has difficulty falling asleep, but then spends the day lying on the couch and reports feeling like he is “moving in slow motion.” He reports feeling tired all the time and has stopped going to his volunteer job at the nursing home. He reports that with the imminent death of his father he is losing his main support. In addition to his father’s illness, the patient was diagnosed and treated for prostate cancer this year and received psychotherapy focused on anxiety about the diagnosis, denial about severity, and end-of-life issues.

PAST PSYCHIATRIC HISTORY: Never hospitalized for psychiatric reasons. No history of suicidal thoughts, gestures, or attempts. Partial or negative response to several antidepressants prescribed by his primary care provider including venlafaxine, fluoxetine, sertraline, escitalopram, and duloxetine. Currently prescribed lorazepam 1 mg BID by his PCP, taken for several years.

MEDICAL HISTORY: GERD, hypertension, hyperlipidemia, and history of prostate cancer. SUBSTANCE HISTORY: Denies drug or alcohol abuse. FAMILY PSYCHIATRIC HISTORY: Mother had depression. PERSONAL HISTORY: Perinatal: No known complications. TRAUMA/ABUSE: Denies.

MENTAL STATUS EXAMINATION: Appearance well-groomed, appropriately dressed, obese. Behavior cooperative, slight unsteady gait, uses walker. Alert and oriented to person, place, time, and situation. Memory intact. Concentration good in interview though reports recent difficulty concentrating while reading. Abstract thought within normal limits. Intellectual functioning: master’s degree. Speech normal rate and rhythm. Perceptions: no abnormalities. Thought processes goal-directed with evidence of guilt and rumination. Thought content anxious, sad, preoccupied with anticipated loss of father. Mood depressed and anxious; affect congruent. Impulse control, judgment, and insight are good.

Assignment: Provide a psychiatric assessment including probable DSM-5 diagnosis(es), differential diagnosis, formulation, and evidence-based treatment plan including pharmacologic and psychotherapeutic recommendations.

Paper For Above Instructions

Clinical Assessment and Diagnostic Impression

Based on the history and mental status exam, the most likely primary diagnosis is Major Depressive Disorder (MDD), single episode or recurrent, moderate severity (DSM-5 criteria: depressed mood, anergia, psychomotor slowing, sleep disturbance, diminished interest/withdrawal, significant functional impairment) (DSM-5, 2013). The symptom pattern is sustained (several months) and produces functional impairment (stopped volunteering, pervasive fatigue). While grief related to impending parental death is prominent, the severity and breadth of symptoms (psychomotor slowing, anergia, functional decline, and history of prior antidepressant trials) support a depressive disorder diagnosis rather than uncomplicated bereavement or adjustment disorder alone (APA, 2010).

Differential Diagnosis

Considerations include:

• Normal bereavement versus MDD: grief-related symptoms can mimic depression; however, pervasive psychomotor slowing, persistent anhedonia and functional impairment favor MDD (DSM-5, 2013).
• Adjustment disorder with depressed mood: possible given recent stressor (father’s illness) but symptoms appear more severe and persistent than typical adjustment disorder (NICE, 2009).
• Depressive disorder due to another medical condition: prostate cancer history and medical comorbidities (HTN, hyperlipidemia) warrant medical evaluation for reversible contributors (thyroid disease, B12 deficiency, medication effects).
• Benzodiazepine-related cognitive/affective effects: long-term lorazepam may contribute to sedation, concentration problems, and falls; benzodiazepines can worsen cognition and mood in older adults (Billioti de Gage et al., 2012).
• Persistent depressive disorder (dysthymia): less likely if symptoms are of more recent onset or clearly reactive to current stressors.

Biopsychosocial Formulation

Biological: Older age, medical comorbidities, prior prostate cancer, and long-term benzodiazepine use increase vulnerability to depression and complicate pharmacotherapy. Partial/negative response to multiple antidepressants suggests possible treatment resistance or inadequate trial/adherence (APA, 2010).

Psychological: Pattern of rumination, guilt, and avoidance of family; preoccupation with loss and anticipatory grief; prior psychotherapy for cancer-related anxiety suggests psychological vulnerability and use of avoidance as coping.

Social: Widowed, identifies father as main support and now facing imminent loss; has adult son and grandchildren but reports not enjoying family interactions, decreased social engagement (stopped volunteering) increasing isolation.

Treatment Plan: Goals and Rationale

Goals: (1) reduce depressive and anxiety symptoms to improve function and quality of life; (2) increase safety and reduce fall/cognitive risk; (3) support grief processing and social reconnection; (4) achieve durable remission and prevent relapse.

Immediate Safety and Assessment

Assess suicidality and self-harm at initial and each follow-up visit despite patient denying history of suicidal ideation. Conduct cognitive screen (MoCA or MMSE) and baseline labs (CBC, CMP, TSH, B12, vitamin D) to identify reversible contributors (Alexopoulos, 2005).

Pharmacologic Recommendations

1. Taper and discontinue long-term benzodiazepine (lorazepam) gradually to reduce fall risk, sedation, and potential contribution to depressive symptoms; implement slow taper plan (e.g., reduce dose by 0.25–0.5 mg every 1–2 weeks with monitoring) and consider substitution with nonbenzodiazepine strategies for anxiety (Billioti de Gage et al., 2012).

2. Initiate or optimize antidepressant therapy tailored to prior partial responses and symptom profile. Given prior trials of SSRIs and SNRIs with partial/negative responses, consider switching to or initiating mirtazapine (beneficial for insomnia, anorexia, and psychomotor slowing in older adults) or bupropion augmentation if anergia and fatigue dominate, bearing in mind bupropion may worsen anxiety (APA, 2010; NICE, 2009). Start at low dose (e.g., mirtazapine 7.5–15 mg nightly) and titrate based on tolerability and response. If inadequate response after adequate trials, consider augmentation strategies (e.g., low-dose atypical antipsychotic like aripiprazole) or referral for ECT for severe, treatment-resistant or biologically severe presentations (Reynolds et al., 1999; Kellner et al., 2005).

3. Monitor drug–drug interactions and medical contraindications; coordinate with PCP to reconcile medications and manage medical comorbidities.

Psychotherapeutic and Psychosocial Interventions

1. Individual grief-focused psychotherapy or interpersonal therapy (IPT) to address anticipatory grief and loss-related interpersonal issues (Cuijpers et al., 2014).

2. Cognitive behavioral therapy (CBT) or problem-solving therapy (PST) adapted for older adults to target rumination, activity scheduling, and re-engagement in meaningful activities; structured behavioral activation can address anergia and social withdrawal (Cuijpers et al., 2014).

3. Referral to bereavement support groups, community resources, volunteer re-engagement when appropriate, and family therapy if relational difficulties can be addressed safely.

Monitoring, Follow-up, and Referral

Follow-up within 1–2 weeks after medication changes and weekly to biweekly therapy sessions initially. Use validated outcome measures (PHQ-9, GAD-7) to track symptoms. If inadequate response after two adequate antidepressant trials, consider consultation with geriatric psychiatry for augmentation strategies, electroconvulsive therapy assessment, or consideration of novel treatments (e.g., transcranial magnetic stimulation where appropriate) (APA, 2010; Reynolds et al., 1999).

Prognosis

Prognosis is guarded but favorable with timely, multimodal intervention: combined targeted pharmacotherapy, evidence-based psychotherapy, discontinuation of potentially harmful benzodiazepines, and social support enhanced. Older adults often respond well to structured interventions when medical contributors are addressed and psychosocial supports are mobilized (Alexopoulos, 2005; Cuijpers et al., 2014).

Summary

This patient presents with a likely major depressive episode exacerbated by anticipatory bereavement and complicated by medical comorbidity and long-term benzodiazepine use. Recommended management includes comprehensive medical workup, discontinuation/taper of lorazepam, targeted antidepressant selection (e.g., mirtazapine) or augmentation if needed, evidence-based psychotherapy focused on grief and behavioral activation, close follow-up with outcome monitoring, and referral to geriatric psychiatry or ECT if treatment-resistant features emerge. These interventions align with current practice guidelines for late-life depression and bereavement-related depressive syndromes (DSM-5, APA, NICE).

References

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). 2013.
• American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 2010.
• National Institute for Health and Care Excellence (NICE). Depression in adults: recognition and management. Clinical guideline CG90. 2009 (updated).
• Alexopoulos GS. Depression in the elderly. Lancet. 2005;365(9475):1961–1970.
• Cuijpers P, Karyotaki E, Weitz E, Andersson G, Hollon SD, van Straten A. The effects of psychotherapies for major depression in adults: a meta-analysis. World Psychiatry. 2014;13(3): 280–287.
• Billioti de Gage S, Begaud B, Bazin F, et al. Benzodiazepine use and risk of dementia: prospective population based study. BMJ. 2012;345:e6231.
• Reynolds CF 3rd, Frank E, Perel JM, et al. Prevention of recurrent major depression in old age by maintenance therapy. JAMA. 1999;281(1):39–45.
• Kellner CH, Knapp R, Husain MM, et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a randomized controlled trial. JAMA. 2006;295(8):1005–1013.
• World Health Organization. Depression fact sheet. 2020.
• American Geriatrics Society Panel. Pharmacological management of late-life depression: considerations and recommendations. Journal of Geriatric Psychiatry. (Guidance synthesized from geriatric clinical resources).