A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A previously healthy 36-year-old man is brought to the physician by a friend because of fatigue and a depressed mood for the past few weeks. During this time, he has not been going to work and did not show up to meet his friends for two bowling nights. The friend is concerned that he may lose his job. He spends most of his time alone at home watching television on the couch. He has been waking up often at night and sometimes takes 20 minutes to go back to sleep. He has also been drinking half a pint of whiskey per day for 1 week. His wife left him 4 weeks ago and moved out of their house. His vital signs are within normal limits. On mental status examination, he is oriented to person, place and time. He displays a flattened affect and says that he “doesn't know how he can live without his wife.” He denies suicidal ideation. Which of the following is the next appropriate step in management?
-
A
Prescribe a short course of alprazolamIncorrect. Alprazolam does not treat depression, increases substance-abuse risk in someone already drinking heavily, and causes dependence — inappropriate as first-line therapy here.
-
B
Initiate cognitive behavioral therapyCorrect. Cognitive behavioral therapy is evidence-based first-line treatment for adjustment disorder and mild-to-moderate depression after a life stressor, particularly in a patient without suicidal ideation.
-
C
Initiate disulfiram therapyIncorrect. Disulfiram is for established alcohol use disorder in patients motivated to abstain; this patient's drinking is brief (1 week) and secondary to the stressor — premature for aversive therapy.
-
D
Hospitalize the patientIncorrect. Hospitalization is reserved for patients with acute suicidality, homicidality, or inability to care for themselves — he denies suicidal ideation and is functioning enough to seek care.
-
E
Refer to inpatient detoxificationIncorrect. Inpatient detoxification is reserved for severe alcohol withdrawal or established alcohol use disorder; one week of drinking after a stressor in a patient without withdrawal signs does not meet criteria for inpatient detox.
↑ Tap an answer to reveal the reasoning
Answer: B. A previously healthy man with depressed mood, anhedonia, social withdrawal, sleep disturbance, and increased alcohol use after a major life stressor (wife's departure 4 weeks ago) — without suicidal ideation — has adjustment disorder with depressed mood or possibly a mild–moderate major depressive episode. He has insight, is oriented, and is functioning sufficiently to attend the visit. He denies suicidal ideation, so hospitalization is not required.
First-line management is psychotherapy — cognitive behavioral therapy or interpersonal therapy — which addresses both the precipitating life event and the maladaptive cognitive patterns sustaining depression. For mild-to-moderate depression in the setting of an identifiable stressor, CBT is at least as effective as antidepressants and avoids medication side effects.
Distinguish: alprazolam would be inappropriate — benzodiazepines do not treat depression, lower the threshold for additional substance abuse (he is already drinking half a pint of whiskey daily), and cause dependence. Disulfiram for alcohol-use disorder is premature; addressing the underlying mood/grief reaction may resolve the alcohol use without aversive therapy. Hospitalization requires acute suicidality, homicidality, or grave self-neglect — none of which he has. Therefore initiating CBT is the next step.
**Why each option:**
**A.** Alprazolam does not treat depression, increases substance-abuse risk in someone already drinking heavily, and causes dependence — inappropriate as first-line therapy here.
**B.** Cognitive behavioral therapy is evidence-based first-line treatment for adjustment disorder and mild-to-moderate depression after a life stressor, particularly in a patient without suicidal ideation.
**C.** Disulfiram is for established alcohol use disorder in patients motivated to abstain; this patient's drinking is brief (1 week) and secondary to the stressor — premature for aversive therapy.
**D.** Hospitalization is reserved for patients with acute suicidality, homicidality, or inability to care for themselves — he denies suicidal ideation and is functioning enough to seek care.