Hello?

Yes, this is psychiatry.

Oh, hi, [gastroenterologist]. Thanks for calling about The Patient.

Right—

—okay—

—and the patient has many reasons that could be contributing to his lack of eating. Depression is unlikely to be a primary cause.

Yes, even though he does have a history of depression does not mean that he is currently depressed. His clinical presentation at this time is most consistent with delirium.

The gastroenterologist opines that he does not believe that the patient is delirious.

Okay. I have been seeing the patient regularly in the intensive care unit for the past three weeks. His mental status has only worsened over that time. He believes he is in the state of Florida. He reports that the current year is 1994 and that his age is 34, even though he was already older than 34 in 1994. There are still occasions when he doesn’t even recognize that he’s in the hospital. He intermittently thinks I’m a nun, a banker, or his roommate. He cannot stay awake long enough to engage in a conversation before his attention drifts off. Nursing staff have also commented that he appears confused and occasionally tries to get out of bed for illogical reasons. These symptoms are not consistent with depression, but are absolutely consistent with delirium, particularly given his very ill condition. Delirium trumps all over psychiatric diagnoses and until the delirium clears, we cannot diagnose another condition.

Yes, of course mirtazapine can improve appetite, but it is not an appetite stimulant! It functions primarily as an antidepressant and, given that the patient is currently delirious, it serves little role in his care.

Okay, and—

—okay. The likelihood that mirtazapine will actually help increase this man’s appetite is really low, given that he is critically ill. It is much more likely that he has an underlying medical condition that is interfering with his appetite and desire to eat. We have all seen his abdomen; it absolutely is distended and has been growing bigger over the past week or so. Could there be a process occurring there? He is endorsing pain—

—yes, and, again, just because someone has a past diagnosis of depression does not mean that he is currently depressed, particularly since he is very ill with [various conditions] and because his clinical presentation isn’t consistent with depression. People who are acutely depressed do not have fluctuations in their levels of consciousness.

Hm?

My recommendation at this time would be to stop the mirtazapine and search for a medical cause for his lack of appetite. His abdomen is distended and—

Right.

Thank you.

The Patient continued to receive the mirtazapine. I tried to empathize with the gastroenterologist—he was, after all, doing his best and using all the tools he knew of to help the patient to eat—and I felt annoyed. There had to be another reason.

Two days later, The Patient underwent an imaging study of his abdomen for unclear reasons. And the radiologists reported that there was free air in the man’s belly.

Air is supposed to stay within the intestines and other organs in the body. “Free air” is air that is no longer contained in organs. That means something popped or tore open. That’s bad.

The Patient was whisked to the operating room for urgent repair of the ruptured organ. And that’s why the patient wasn’t eating.