A 79-year-old man is brought to the

A 79-year-old man is brought to the emergency department by his family. Although the patient is essential mute, his family member report he has had a history of numerous episodes of depression, the last occurring 6 years ago. At that time, he was hospitalized and treated with sertraline. He has been hospitalized a total of four time for depression, but the family denies that he has ever been treated for mania. The patient’s only current medication is hydrochlorothiazide. However, he has refused to take it for the past 2 days. The current episode of depression, similar to previous ones, began 3 weeks prior to the emergency department visit. The patient has had frequent crying episodes and has complained of a decrease in energy. He has lost at least 15 lb. in the 3 weeks and for the past 2 days has refused to eat anything at all. Three days ago, the patient told his family that he was “sorry for all the pain and suffering I have caused you” and that “it would be better if I were not around anymore.” Two days ago, he stopped speaking and eating, and for the past 24 hours he has refused to take anything by mouth including water. After rehydration in the emergency department, the patient was admitted to the psychiatry service. The results of his physical examination were essentially normal, although is blood pressure was 150/92 mm Hg, and he exhibited psychomotor slowing. The patient refused all attempts to feed him by mouth. When asked if he was suicidal, he nodded his assent, as well as nodding to the , “Are you hearing voices?” What is the most likely diagnosis and differential diagnoses? What is the best plan of action for this patient and why?

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