PCP with feelings of hopelessness, sadness, and helplessness.

Full Answer Section

        Potential DSM-5-TR Diagnosis Based on the information provided, the patient exhibits symptoms consistent with Major Depressive Episode (MDE) according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) [1]. Here's a breakdown of the relevant criteria:

• Depressed mood: The patient reports feelings of sadness and hopelessness.
• Loss of interest or pleasure: Decreased motivation to go to work suggests a potential loss of interest in previously enjoyable activities.
• Significant weight loss or gain: Information regarding weight changes is not provided but can be assessed during further evaluation.
• Psychomotor agitation or retardation: Details are lacking, but withdrawal and tearfulness could suggest psychomotor changes.
• Fatigue or loss of energy: Sleep disturbances and a lack of ability to cope imply potential fatigue.
• Feelings of worthlessness or excessive guilt: Hopelessness and helplessness may indicate feelings of worthlessness.
• Diminished ability to think or concentrate: Cognitive difficulties are not explicitly mentioned but may be explored during a comprehensive evaluation.
• Recurrent thoughts of death (not just fear of dying), suicidal ideation without a specific plan, or a suicide attempt or plan for a specific suicide: The patient reports suicidal ideation.

The duration of symptoms (6 weeks) meets the DSM-5-TR criteria for a major depressive episode. However, a full diagnosis requires a comprehensive clinical evaluation to assess the severity of symptoms, rule out other potential explanations for the patient's presentation, and determine the presence of additional mental health conditions. Pharmacological Treatment Considerations Given the severity of the patient's symptoms, including suicidal ideation, initiating pharmacological treatment alongside non-pharmacological interventions is crucial. Selective Serotonin Reuptake Inhibitors (SSRIs) are a first-line treatment option for MDE due to their efficacy, safety profile, and tolerability [2]. Here's a potential medication selection:

• Medication: Escitalopram (Lexapro)
• Dose: Starting dose of 10mg daily, with potential for dose adjustments based on clinical response and tolerability.
• Route: Oral administration (tablet)
• Frequency: Once daily

Rationale:

• Efficacy: Research demonstrates the effectiveness of SSRIs in reducing symptoms of depression [2]. Escitalopram is a well-studied SSRI with a proven track record in treating MDE.
• Safety: SSRIs have a relatively low risk of serious side effects compared to other classes of antidepressants [2].
• Tolerability: SSRIs are generally well-tolerated, with common side effects including nausea, dry mouth, and sexual dysfunction. These often subside over time.

Appropriateness: Considering the patient's symptoms and potential suicide risk, pharmacological intervention is warranted alongside other treatment modalities. Cost and Effectiveness: Escitalopram is a generic medication, making it a more cost-effective option compared to brand-name SSRIs. Using a local pharmacy search, the estimated cost for a one-month supply of 10mg escitalopram tablets can range from $10 to $30. The cost-effectiveness is further enhanced by its effectiveness in managing MDE. Safety and Adherence:

• Safety: Escitalopram is generally well-tolerated, but close monitoring is necessary to identify potential side effects and interactions with other medications.
• Adherence: SSRIs typically require several weeks to show their full effects. Educating the patient about the treatment plan and the importance of adherence is crucial. Regular follow-up appointments can help monitor progress and address any concerns about side effects that might lead to non-adherence.

Non-Pharmacological Treatment: Exercise Exercise is a non-pharmacological intervention with established benefits for treating depression [3]. Here's why this is a suitable option for this case:

• Effectiveness: Physical activity has been shown to improve mood, reduce stress, and enhance sleep quality – all areas potentially impacted in this patient.
• Accessibility: Engaging in physical activity does not require specialized equipment or a significant financial investment.
• Complementary to Medication: Exercise can work synergistically with medication to achieve optimal treatment outcomes.

Appropriateness: Exercise poses minimal risks and can be beneficial for overall physical and mental health. Given the patient  

Sample Solution

      A 41-year-old male patient presents to his primary care physician (PCP) with symptoms suggestive of a major depressive episode. He reports feelings of hopelessness, sadness, and helplessness, accompanied by tearfulness and sleep disturbances. The patient indicates a six-week timeframe for these symptoms and an inability to cope effectively. He describes increased alcohol consumption and work withdrawal. Additionally, he acknowledges suicidal ideation involving self-harm by driving into a canal.