A 60 year male is brought by his wife. He thinks that he had committed sins all through his life. He is very much depressed and has considered committing suicide but has not thought about going for it. He had also attached sessions with a spiritual guru. He is not convinced by his wife that he has lead a pious life. He does not want to hear anything on the contrary. How will you treat him ?

**Core Concept**
Depression with spiritual or existential guilt, often presenting with feelings of worthlessness and hopelessness, requires a nuanced approach combining psychotherapy and pharmacotherapy.

**Why the Correct Answer is Right**
This patient is experiencing a form of depression known as "spiritual crisis" or "existential guilt," where an individual feels overwhelmed by their perceived moral failings. The presence of suicidal ideation necessitates a comprehensive treatment plan. Pharmacotherapy with antidepressants, specifically Selective Serotonin Reuptake Inhibitors (SSRIs), can help alleviate depressive symptoms. In conjunction with pharmacotherapy, a form of psychotherapy like Cognitive Behavioral Therapy (CBT) or Psychodynamic Therapy can be employed to address the underlying spiritual and existential concerns. The involvement of a spiritual guru may be a part of his coping mechanism, but its efficacy in treating depression needs to be evaluated.

**Why Each Wrong Option is Incorrect**
**Option A:** This option is incorrect because simply prescribing medication without addressing the patient's underlying spiritual and existential concerns may not lead to a complete resolution of symptoms.

**Option B:** This option is incorrect because referring the patient for counseling without considering the severity of his depression and suicidal ideation may not be sufficient.

**Option C:** This option is incorrect because only attaching him to the spiritual guru without any medical intervention may not address the patient's acute depression and suicidal ideation.

**Clinical Pearl / High-Yield Fact**
In patients presenting with spiritual or existential guilt, it's essential to maintain a non-judgmental and empathetic attitude while exploring their spiritual and existential concerns. This can help establish a therapeutic alliance and facilitate the treatment process.

**Correct Answer: C.** Consult the spiritual guru while providing appropriate medical intervention.

✓ Correct Answer: A. Antipsychotic + Antidepressant