Tutor’s Guide for PCL 1 Case 6
The Case of James Carter M.D.
2011-2012
Case Development Team:
Jeff Akman, MD
Department of Psychiatry
Julia Frank, MD
Department of Psychiatry
Matthew Mintz, MD
Department of Medicine
Seema Kakar MD
Department of Medicine
The case has five major objectives (questions to be answered). It also involves practice in case
presentation and in biopsychosocial formulation:
1. How does the care of depression by primary care physicians resemble and differ from that
provided by psychiatrists? How does the descriptive, empirical DSM help or discourage
adequate recognition and treatment of depression?
2. How do anxiety, depression and substance abuse interact with each other?
3. What is involved in assessing suicide risk, and how should one intervene with a patient who may
be at risk for suicide?
4. How does stigma complicate both the care of people with psychiatric disorders and those who
are members of populations that are stigmatized by the wider society?
5. What legal and ethical issues are involved in dealing with an impaired physician?
Overview of the Case
This case presents a clinical example of major depression in a gay male physician with emphasis on
differential and comorbid diagnoses, risk assessment, and the role of interpersonal processes in causing
or precipitating depression and/or enchancing recovery. After a medical work up that rules out both
common and rare but serious diseases that might cause depression, the patient is referred for
psychotherapy and started on an anti-depressant. The patient is homosexual , which leads to discussion
of physicians’ relationships, principles of psychotherapy and psychopharmacology, and the role of
discrimination in contributing to both substance abuse and suicidal behavior in minority groups. All
students are expected to prepare a biopsychosocial case formulation, followed by a group discussion of
the treatment of depression in relation to both DSM diagnosis and case formulation.
Session I
The case opens with an interview between Dr. Carter, a first year resident in anesthesiology, and Dr.
Coe, a primary care physician. Dr. Carter comes for intense fatigue, aches and pains, and weight loss and
is concerned he could have leukemia or some systemic malignancy. The initial interview (Handout 1)
elicits symptoms of depression, followed by a normal physical exam and an appropriate laboratory
evaluation (Handout 2). Time should be spent on differential diagnosis and clinical reasoning before
going to the Follow up Visit (Handout 3)
Session II
The second session begins with an interview (Handout 4) between Dr. Carter and Dr. Booker, a
psychiatrist who takes a more complete psychosocial history. Dr. Booker finds that Dr. Carter, who is
gay, is having problems in his primary intimate relationship. Dr. Carter also reveals a history of an
adolescent suicide attempt and admits to coming close to attempting suicide the previous week. Dr.
Carter also describes having a panic attack. Dr. Carter is a candidate for both medication and several
types of psychotherapy. A brieffollow-up interview (Handout 5) ends the presentation of material. At
the end of the second session, all students are assigned to prepare a biopsychosocial formulation of Dr.
Carter’s case, based on the information they have received, in addition to whatever objectives they are
to research. (The biopsychosocial formulation should relate to the information from both handout 1 and
handout 4).
Session III
The third session includes a discussion of the objectives from the previous two sessions. Following that
discussion, students should present and compare their formulations. Sample board review questions are
provided for discussion (Handout 6).
Management of the First Small Group Session
1. Distribute Handout 1, Interview between Dr. Carter and Dr. Coe and ask two students to role
play the interview.
2. Discuss issues related to diagnosis of fatigue and depression, descriptive versus other types of
diagnosis, and the appropriate medical evaluation of this patient’s complaints.
3. Discuss the the importance of prioritizing most likely to least likely diagnoses based on the
symptoms and age/gender/circumstances of the patient, while still keeping in mind rare but
serious or life-threatening possibilities. Focus on clinical reasoning in deciding which tests
should be ordered and which are not necessary. Consider in class research to clarify some
questions that arise (example: “what is lymphoma vs. leukemia?”)
4. Distribute Handout 2 (physical and lab work). After seeing this, the students are likely to be
fairly certain that depression is the primary diagnosis. They should discuss what other
information they would like to have to confirm or support depression as the diagnosis and how
this type of assessment differs somewhat from the “rule out/rule in by objective tests”
methods of most medical care.
5. Role play the second interview between Dr. Coe and Dr. Carter (Handout 3).
Discuss Dr. Coe and Dr. Carter’s interview
6. Formulate objectives for half the class to research. If the medical differential diagnosis of
fatigue has not been adequately covered in class, that can be an objective, but students should
also research other issues, including concerns about whether a depressed physician should be
considered impaired and what that means, the comorbidity of depression, anxiety and alcohol
use, and whether primary care physicians do, can or should treat depression.
7. Assign a student to give an oral presentation of James Carter at the beginning of the next
session, based on handouts 1-3. (At the beginning of the third session, another student should
present the case based on 1-4).
Questions for discussion
1. What medical conditions might present with intense fatigue? What would you look for on
physical exam? What lab work or imaging study might be indicated?
2. What psychiatric conditions might present with intense fatigue?
3. Of the conditions you’ve mentioned, which are most likely to be present in a young adult male?
How do you identify the presence of these conditions?
4. If a patient meets criteria for more than one DSM disorder, what might one do to establish
which disorder to treat? What does comorbidity imply about the limits of a DSM approach to
diagnosis?
5. What are risk factors and how do they differ from clinical criteria for making diagnoses?
Additional questions after handout 3
Now that we have ruled out most common medical conditions, major depression is the most
likely diagnoses in this patient.
1. What aspects of his history contribute to this diagnosis? What information that was not
gathered at this interview would be helpful in confirming this diagnosis?
2. What is the neurobiology of depression?
3. How does alcohol use contribute to the development or maintenance of
depression?
4. What psychosocial factors contribute to depression? How does the thinking of a
depressed person differ from that of someone who is not depressed? Can you find
examples of depressive thought in the first interview?
5. How commonly is depression diagnosed or treated by primary care practitioners?
When should a depressed patient be referred to a specialist? How is specialty care
different, and does it influence the outcome of treatment?
Management of the Second Small Group Session
Start with the oral case presentation. Please elicit and give feedback.
Appoint a scribe, and then ask the students discuss their research from the previous week.
By the beginning of the second hour, ask two students to role play the interviews between Dr. Booker
and Dr. Carter (Handout 4) and identify new discussion objectives: risk assessment, homosexuality,
especially in relation to adolescent suicide and stigma, and the interpersonal relationships of all
physicians, and the nature and outcome of psychotherapy for depression.
.
At the end of the session assign one student to present the case again next week, from the point they
have now reached. Assign all students to prepare a biopsychosocial formulation of Dr. Carter’s case for
discussion next week.
Questions for discussion
1. What are the elements of “risk assessment” described above? What does it mean to “contract
for safety?”
2. How common is suicidal behavior in homosexual adolescents? Is the rate higher than that for
other teenagers? What are the determinants of this behavior?
3. What barriers prevent gay men and lesbians from receiving adequate health care? For example,
at the time JC made his suicide attempt, what might have been the reasons that he did not seek
and was not given medical help?
4. In what ways are Dr. Carter’s relationship problems typical for a couple in which one partner is
in medical training? (Students who are married or in committed relationships should be
encouraged to talk about their own experiences).
5. What aspects of the problem seem unique to a homosexual relationship? How does the
relationship problem figure in the precipitating of Dr. Carter’s depression? Could the depression
contributing to the relationship problem?
6. What kinds of treatment approach(es) might address the psychosocial issue(s) identified? What
are the basic principles of brief psychotherapies, especially cognitive behavioral therapy,
interpersonal psychotherapy, and psychodynamic psychotherapy?
Background material: