Psychiatry · Year 3 · from Psychiatry
Case 3: Depression in the Medically Ill
Consultation Request
"56 y/o man with recent MI, now seems depressed, not participating in cardiac rehab. Please evaluate."
Patient Demographics
- Age: 56 years old
- Sex: Male
- Occupation: Construction foreman
- Current Location: Cardiac rehabilitation unit
History of Present Illness (from chart and cardiology)
The patient is a 56-year-old man who suffered a large anterior STEMI 3 weeks ago, treated with emergent PCI to the LAD. His ejection fraction is 35% (reduced). He has been medically stable and was transferred to inpatient cardiac rehabilitation.
However, cardiac rehab staff reports he has been refusing to participate in exercise sessions, stating "what's the point?" He has been withdrawn, not interacting with other patients or staff, and has poor appetite with 8 lb weight loss. Nursing notes he stares at the ceiling for hours and has been tearful. He told a nurse "I might as well have died" yesterday.
Psychiatric Consultation Interview
Review of Systems (Endicott Substitutive Criteria):
- Fatigue - present, but also expected post-MI
- Sleep: Poor, waking early, not explained by medical factors
- Appetite: Markedly decreased, worse than expected
- Psychomotor: Slowing noted, worse than expected post-MI
- Concentration: Impaired
Psychiatric History:
- One episode of depression in his 30s after divorce, treated with "pills" for about a year
- No prior suicide attempts
- No substance abuse (quit smoking after MI)
Social History:
- Divorced, lives alone
- Two adult children (strained relationships)
- Work is "everything to me" - unsure if he can return to construction
- No close friends
- Sister died of heart disease at age 52
Mental Status Examination:
Appearance: Middle-aged man in hospital gown, unshaven for several days, lying in bed facing wall
Behavior: Slow to engage, minimal eye contact, long pauses before answering
Speech: Slow rate, soft volume, impoverished content
Mood: "Empty... broken"
Affect: Depressed, flat, tearful at times
Thought Process: Linear but impoverished, slowed
Thought Content:
- Hopelessness: "My life is over. I'll never work again."
- Worthlessness: "I can't even do a simple exercise without getting winded. I'm useless."
- Guilt: "I did this to myself with smoking and eating garbage."
- Passive suicidal ideation: "I wish I hadn't survived the heart attack."
- Denies active suicidal ideation, plan, or intent: "I wouldn't do anything. I just wish it was over."
Cognition: Alert, oriented, concentration impaired by depression
Assessment
Differential Diagnosis:
- Major depressive disorder
- Adjustment disorder with depressed mood
- Demoralization (not a DSM diagnosis but common post-MI)
- Cardiac rehab-related fatigue (some overlap)
Important Consideration - Endicott Criteria:
Standard depression criteria include neurovegetative symptoms (fatigue, poor appetite, sleep changes) that overlap with medical illness. The Endicott criteria substitute psychological symptoms:
- Fearfulness/depressed appearance (instead of appetite/weight)
- Social withdrawal (instead of fatigue)
- Brooding/pessimism (instead of concentration)
- Cannot be cheered up (instead of sleep changes)
Using Endicott criteria, this patient clearly meets criteria for major depression beyond what would be expected from cardiac illness alone.
Diagnosis
Major Depressive Disorder, Recurrent, Moderate (F33.1)
Evidence:
- Prior episode (in 30s)
- Current episode with:
- Depressed mood
- Anhedonia (not participating in anything, nothing enjoyable)
- Sleep disturbance (worse than expected)
- Psychomotor retardation
- Worthlessness, guilt
- Hopelessness
- Passive suicidal ideation
- Duration >2 weeks
Significance:
- Post-MI depression affects ~20% of patients
- Depression is an independent risk factor for cardiac mortality
- Untreated depression impairs cardiac rehab participation and medication adherence
- Treatment improves both depression and cardiac outcomes
Treatment Recommendations
1. Safety:
- Passive suicidal ideation without plan or intent - low imminent risk
- Safety plan discussed
- Staff awareness for monitoring
2. Pharmacotherapy - SSRI:
- Sertraline 25 mg daily, increase to 50 mg in 1 week
- Most evidence for cardiac safety post-MI
- SADHART trial showed safe and effective in post-MI depression
- Minimal cardiac effects
- Avoid TCAs (cardiac conduction effects, QTc prolongation)
- Use caution with medications that affect platelets/bleeding
3. Psychotherapy:
- Problem-solving therapy (brief, focused, effective for depression)
- Behavioral activation: Set small, achievable goals
- Address specific cognitive distortions about being "broken" and "useless"
- Motivational enhancement for cardiac rehab participation
4. Cardiac Rehab Integration:
- Work with rehab team to set modified goals
- Frame exercise as treatment for depression (evidence-based)
- Small wins to build self-efficacy
5. Social Support:
- Social work consult: Assess discharge needs, living situation
- Explore family relationships - can adult children visit?
- Peer support: Cardiac recovery support group
6. Address Specific Concerns:
- Work: Discuss with occupational therapy - modified work may be possible
- Meaning and identity: His identity is wrapped up in physical work - needs to expand sense of purpose
Follow-up Plan
Inpatient:
- Daily psychiatry contact while in cardiac rehab
- Monitor suicidality, response to medication
- Coordinate with rehab team
Discharge:
- Outpatient psychiatry within 1 week
- Outpatient therapy referral
- Continue sertraline, titrate as needed
- Ongoing cardiac rehab (outpatient)
- Monitor for improvement in depression and cardiac outcomes
Prognosis Discussion
With Treatment:
- Depression is highly treatable
- Treatment improves cardiac rehab participation
- Treatment reduces cardiac mortality risk
- Most patients recover fully from depression
Without Treatment:
- Depression tends to persist/worsen
- Increased cardiac mortality (2-3x risk)
- Poor medication adherence
- Worse functional outcomes
Image Attribution
Image: Diagram illustrating the biopsychosocial model in consultation-liaison psychiatry showing the bidirectional relationship between medical illness and psychiatric symptoms. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.