A 64-year-old physician with no history of psychiatric problems reports that over the past 3 months

[Medicoman]

A 64-year-old physician with no history of psychiatric problems reports that over the past 3 months he has been having difficulty sleeping through the night and has lost his appetite for food. He states that if he had been a better doctor, some of his patients would not have died, and he expresses guilt about not spending more time with his children when they were young. The patient also reports that he has lost 25 pounds since the previous year. The most appropriate next step in the management of this patient is

• 1. an antipsychotic
• 2. an antidepressant
• 3. a medical evaluation
• 4. psychotherapy
• 5. a benzodiazepine

exp:

The most appropriate next step in the management of this depressed patient, who has no previous history of psychiatric illness, is a medical evaluation. This patient has symptoms of depression including sleep problems, inappropriate guilt, suicidal ideation, and significant weight loss. Because of his age and because pancreatic cancer and other gastrointestinal cancers not uncommonly present with depression, this patient should be evaluated for such conditions prior to treating his depression. As in question 7, psychotherapy, antidepressants, and benzodiazepines do not address this patient’s underlying physical problem.