case study

Family Medicine 03: 65-year-old female with insomnia User: Monica Morales Email: [email protected] Date: January 29, 2024 6:17 PM

Learning Objectives

The student should be able to:

Summarize the key features of a patient presenting with depression capturing the information essential for differentiating between the common and “don’t miss” etiologies.

Describe the initial management of patients who present with insomnia.

Interpret information from a patient history and examination to determine that depression is the most likely diagnosis.

Describe common effects and side effects of antidepressant medications.

Describe the initial management of depression including therapy and pharmaceutical options.

Describe the initial management of common diagnoses that present with dementia.

Conduct a focused history and physical exam appropriate for differentiating between common etiologies of a patient presenting with insomnia in the elderly.

Conduct a focused history and physical exam appropriate for differentiating between common etiologies of a patient presenting with depression.

Describe the initial management of patients who present with depression.

Discuss depression in the context of culture and social determinants of health.

Discuss who should be screened for elder abuse depending on gender, age, and risk.

Communicate respectfully with a patient who does not fully adhere to their treatment plan for depression.

Elicit a focused history that includes information about self-management of depression.

Elicit a focused history that includes information about self-management of insomnia.

Give examples of health care disparities.

Knowledge

Common Causes of Insomnia in the Elderly

1. Issues that may lead to an environment that is not conducive to sleep .

Specific examples include: noise or uncomfortable bedding.

2. The use of prescription, over-the-counter, alternative, and recreational drugs might affect sleep.

Patients should be counseled to avoid caffeine and alcohol for four to six hours before bedtime.

3. Sleep apnea is common in the elderly, occurring in 20% to 70% of elderly patients.

Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep.

4. In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations.

5. In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively.

As with sleep apnea, the sleeper is often unaware of these behaviors and a bed partner or family member may need to be asked about these movements.

6. Disturbances in the sleep-wake cycle include jet lag and shift work.

7. Patients with depression and anxiety commonly present with insomnia.

Any patient presenting with insomnia should be screened for these disorders.

8. Patients with shortness of breath due to cardiorespiratory disorders often report that these symptoms keep them awake.

9. Pain or pruritus may keep patients awake at night.

10. Those with GERD may report heartburn, throat pain, or breathing problems.

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Detailed questioning may be needed to elicit the symptoms of this disorder.

11. Elderly patients with hyperthyroidism frequently do not present with typical symptoms such as tachycardia or weight loss, and laboratory studies may be required to detect this problem.

12. Circadian rhythms change, with older adults tending to get sleepy earlier in the night. In advanced sleep phase syndrome (ASPS) , this has progressed to the point where the patient becomes drowsy at 6 to 7 p.m. If they go to sleep at this hour, they sleep a normal seven to eight hours, waking at 3 or 4 a.m. However, if they try to stay up later, their advanced sleep/wake rhythm still causes them to awaken at 3 or 4 a.m. This can be difficult to distinguish from insomnia.

Good Sleep Hygiene

You can teach the patient sleep hygiene techniques that will increase the likelihood of a restful night's sleep.

Your Personal Habits

Fix a bedtime and an awakening time. The body "gets used to" falling asleep at a certain time, but only if this is relatively fixed. Even if you are retired or not working, this is an essential component of good sleeping habits.

Avoid napping during the day. If you nap throughout the day, it is no wonder that you will not be able to sleep at night. The late afternoon for most people is a "sleepy time." Many people will take a nap at that time. This is generally not a bad thing to do, provided you limit the nap to 30 to 45 minutes and can sleep well at night.

Avoid alcohol four to six hours before bedtime. Many people believe that alcohol helps them sleep. While alcohol has an immediate sleep-inducing effect, a few hours later as the alcohol levels in the blood start to fall, there is a stimulant or wake-up effect.

Avoid caffeine four to six hours before bedtime. This includes caffeinated beverages such as coffee, tea and many sodas, as well as chocolate.

Avoid heavy, spicy, or sugary foods four to six hours before bedtime. These can affect your ability to stay asleep.

Exercise regularly, but not right before bed. Regular exercise, particularly in the afternoon, can help deepen sleep. Strenuous exercise within two hours before bedtime, however, can decrease your ability to fall asleep.

Your Sleeping Environment

Use comfortable bedding. Uncomfortable bedding can prevent good sleep. Evaluate whether or not this is a source of your problem, and make appropriate changes.

Find a comfortable temperature setting for sleeping and keep the room well ventilated. If your bedroom is too cold or too hot, it can keep you awake. A cool (not cold) bedroom is often the most conducive to sleep.

Block out all distracting noise, and eliminate as much light as possible.

Reserve the bed for sleep and sex. Don't use the bed as an office, workroom or recreation room. Let your body "know" that the bed is associated with sleeping.

Getting Ready For Bed

Try a light snack before bed. Warm milk and foods high in the amino acid tryptophan, such as bananas, may help you to sleep.

Practice relaxation techniques before bed. Relaxation techniques such as yoga, deep breathing and others may help relieve anxiety and reduce muscle tension.

Don't take your worries to bed. Leave your worries about job, school, daily life, etc., behind when you go to bed. Some people find it useful to assign a "worry period" during the evening or late afternoon to deal with these issues.

Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of reading, can help you sleep.

Get into your favorite sleeping position. If you don't fall asleep within 15 to 30 minutes, get up, go into another room, and read until sleepy.

Turn off all electronic devices at least 30 minutes before bedtime. The artificial light generated by a laptop, tablet, or cell phone screen can interfere with your body’s sleepiness cues.

Getting Up in the Middle of the Night

Most people wake up one or two times per night for various reasons. If you find that you get up in the middle of night and cannot get back to sleep within 15 to 20 minutes, then do not remain in the bed "trying hard" to sleep. Get out of bed. Leave the bedroom. Read, have a light snack, do some quiet activity, or take a bath. You will generally find that you can get back to sleep 20 minutes or so later. Do not perform challenging or engaging activities such as office work, housework, etc. Do not watch television.

Risk Factors for Completed Suicide

Sex: The person most likely to complete a suicidal attempt is an adult male. While females are more likely to attempt suicide, males are more likely

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to complete one.

Age: Although overall suicidal behaviors do not increase with age, rates of completed suicide do increase with age .

Older adults attempting suicide are also more likely to be widows/widowers, live alone, perceive their health status to be poor, experience poor sleep quality, lack a confidante, and experience stressful life events.

Importantly, approximately 45% of older adults who die by suicide had visited a primary care physician within the preceding month, underscoring the importance for physicians to be alert to the signs and symptoms of depression and risks for suicide. Drug overdose is the most common means of suicide in older adults, making the safety of medications chosen to treat the condition important.

Previous attempts: Having previously attempted suicide is a risk factor for completed suicide.

Military Service: The suicide rate of military veterans in the United States is higher than that of the general population.

Poverty by itself has not been found to be a risk factor for completed suicide, though it can contribute to psychosocial stress and the development of depressive symptoms.

Major Depression Diagnostic Criteria

For a diagnosis of major depression, the patient must have at least five of the following nine criteria for a minimum of two weeks.

A least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure.

Depressed Mood

(The eight remaining criteria can be remembered using the mnemonic SIG E CAPS):

Sleep: Insomnia or hypersomnia nearly every day.

Interest (loss of): Anhedonia (loss of interest or enjoyment) in usual activities.

Guilt: Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

Energy (decreased): Fatigue or loss of energy nearly every day.

Concentration (decreased, or crying): Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

Appetite (increased or decreased): or significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month).

Psychomotor retardation: Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

Suicidal ideation: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for suicide.

Major Depressive Disorder versus Bereavement

The presence of certain symptoms that are not characteristic of a "normal" grief reaction may be helpful in differentiating bereavement from a major depressive episode. The table below adapted from the DSM V discusses some potential differences:

Major depressive episode Bereavement (grief)

Persistent depressed mood and inability to anticipate happiness or pleasure Feelings of emptiness and loss

Depression persistent, not tied to specific thoughts or preoccupations

Depressed feelings often decrease in intensity over days to weeks and occur in waves, associated with thoughts of the deceased

Pervasive unhappiness and misery Grief may be accompanied by positive emotions and humor

Self-critical or pessimistic ruminations Preoccupation with thoughts and memories of the deceased

Feelings of worthlessness and self-loathing Self-esteem is generally preserved. May be self-deprecating—feeling they should have done more or told the deceased how much he or she was loved

Suicidal ideation because of feeling worthless, undeserving of life, or unable to cope with the pain of depression

Individual thinks about death and dying, generally focused on the deceased and possibly about joining the deceased

Risk Factors for Late-Life Depression

Risk factors for late-life depression include:

Female sex

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Social isolation

Widowed, divorced, or separated relationship status

Lower socioeconomic status

Comorbid general medical conditions, e.g., stroke, heart disease, and cancer

Uncontrolled pain

Insomnia

Functional impairment

Cognitive impairment

Depression in Older Adults

Depression is a very serious disease in older adults:

Depression increases the risk of disabilities in mobility and the activities of daily living by about 70% over the course of six years.

Alcohol and drug abuse are very common comorbidities complicating depression.

Completed suicide is more common in older depressed patients.

Suicide Assessment Five-step Evaluation and Triage (SAFE-T)

Suicide Assessment Five-step Evaluation and Triage (SAFE-T)

1. RISK FACTORS

a. Suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior

b. Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity) Co-morbidity and recent onset of illness increase risk

c. Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, and command hallucinations

d. Family history: of suicide, attempts, or psychiatric disorders requiring hospitalization

e. Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g., loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation

f. Change in treatment: discharge from psychiatric hospital, provider or treatment change

g. Access to firearms

2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk

a. Internal: ability to cope with stress, religious beliefs, and frustration tolerance

b. External: responsibility to children or beloved pets, positive therapeutic relationships, and social supports

3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, and intent

a. Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever

b. Plan: timing, location, lethality, availability, and preparatory acts

c. Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) versus non-suicidal self injurious actions

d. Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal versus self-injurious.

e. Explore ambivalence: reasons to die versus reasons to live

For youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition

Homicide inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above

4. RISK LEVEL/INTERVENTION

a. Assessment of risk level is based on clinical judgment, after completing steps 1–3

b. Reassess as patient or environmental circumstances change

5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with significant others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plans should include roles for parent/guardian.

Screening for Depression

The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression , especially patients with chronic diseases like diabetes, as they are at high risk for depression.

The PHQ-2 is a simple screen that is 97% sensitive and 59% specific as a depression screen:

"Over the past two weeks, have you often been bothered by either of the following problems?"

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1. Little interest or pleasure in doing things.

2. Feeling down, depressed, or hopeless.

If positive, it should be followed up by a diagnostic instrument such as:

PHQ-9

Geriatric Depression Scale - Short Form (GDS-SF)

Screening for Dementia in Geriatric Patients with Depression

While screening for dementia in asymptomatic individuals is not recommended (I statement), screening is important in geriatric patients with depression because the Geriatric Depression Scale is less sensitive in patients experiencing dementia.

Two dementia screening tools are:

The Mini-Cog exam

The Mini-Mental State Exam (MMSE)

The Mini-Cog exam is faster and more sensitive and specific than the MMSE.

Sensitivity Specificity

Mini-Cog 99% 93%

MMSE 91% 92%

Patient Health Questionnaire, Two-Item Version (PHQ-2)

The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. Many family physicians and students are familiar with the nine-item depression survey from the Patient Health Questionnaire (PHQ-9), which has been demonstrated to be useful in diagnosis and tracking the severity of symptoms among patients with major depression. The length of the questionnaire has been a barrier to its use as a screening tool in primary care, where physicians are under considerable time pressure and face competing demands.

More recently, a shortened two-item version (PHQ-2) has been developed and validated in primary care. The PHQ-2 asks patients, "Over the last two weeks, how often have you been bothered by any of the following problems?" The two symptoms are "little interest or pleasure in doing things" and "feeling down, depressed, or hopeless." For each question the patient can answer:

Not at all (0 points)

Several days (1 point)

More than half the days (2 points)

Nearly every day (3 points)

The score from the two symptom questions are then added together into a final score.

Side Effects of SSRI/SNRIs

Common side effects of SSRI/SNRIs include:

Headaches

Sleep disturbances (drowsiness and, less frequently, insomnia)

Gastrointestinal problems such as nausea and diarrhea

Sexual dysfunction

They can also cause:

Hyponatremia, due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

Serotonin syndrome (lethargy, restlessness, hypertonicity, rhabdomyolysis, renal failure, and possible death)

Increased risk of gastrointestinal bleeding

In olde adults you also have to be concerned about an increased risk for falls with these medications, and recent studies show that they might have adverse effects on bone density.

Older antidepressants such as TCAs can cause arrhythmias. Citalopram and escitalopram can cause QT interval prolongation at higher doses, especially in the face of hypokalemia and hypomagnesemia or when combined with other medications that have this same effect. Reports of symptomatic arrhythmia are uncommon.

Often patients with depression will present with arthralgias and myalgias, but SSRI/SNRIs do not cause arthralgias.

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Depression in Diverse Populations

In the U.S., Black and Hispanic/Latino individuals experience longer lasting depressive symptoms than non-Hispanic White individuals. Hispanic/Latino patients are less likely to receive mental health care than non-Hispanic whites. Among adults with any mental illness, 48% of non- Hispanic White individuals received mental health services while only 31% of Black and HIspanic/Latino individuals and 22% of Asian individuals received services.

Non-Hispanic White individuals are more likely to die by suicide than people of other racial and ethnic groups.

It is important for clinicians to recognize that there are inequities in outcomes for minority patients with depression and to take steps to mitigate them. Such steps could include patient-centered communication, addressing social determinants of health, and reflection about implicit biases.

Non-Hispanic White individuals (35%) have higher documented rates of depression than Black (25%) and Hispanic/Latino (20%) individuals.

Definition of Racial and Ethnic Disparities

Although race is a social construct and not a marker of biological difference, the ways that race has been used over the centuries to determine differential access and rights have had real effects on health, leading to racial and ethnic health disparities. For example, pregnancy-related mortality for Black, American Indian, and Alaskan Native people is two to three times higher than for White, Hispanic/Latino, and Asian/Pacific people, regardless of socioeconomic status or education level. The causes of this disparity are not well understood, but systemic discrimination and implicit racial bias in medical treatment are thought to play a role. Some proposed interventions to mitigate this disparity include using standardized protocols in the hospital and addressing implicit bias in the health care workforce. More information about implicit bias can be found later in this case.

Elder Abuse

Early research indicates the following risk factors for elder abuse:

1. Dementia.

2. Shared living situation of elder and abuser (except in financial abuse).

3. Caregiver substance abuse or mental illness.

4. Heavy dependence of caregiver on elder. Surprisingly, the degree of an elder's dependency and the resulting stress has not been found to predict abuse.

5. Social isolation of the elder from people other than the abuser.

Clinical Skills

Complementary and Alternative Therapies

When obtaining a medication history, health care providers should ask routinely about herbal and other supplements—as well as over-the-counter medications and nutritional supplements. Patients frequently will not mention the use of complementary and alternative medical treatment unless they are asked about them. Be respectful when patients discuss alternative therapies, even if you are unfamiliar or skeptical about a particular treatment.

Herbs and similar supplements are a concern because of their potential to interact with conventional medications or produce side effects, just like conventional drugs. Even where they were obtained is important, as supplements have repeatedly been found to be contaminated with other herbs, heavy metals, and even prescription drugs. Only a few herbs have been scientifically studied, so information on their effectiveness is limited. St. John's Wort has been shown possibly to be effective for short-term treatment of mild to moderate depression but data from trials is mixed.

Management

Treatments for Primary Insomnia in Older Adults

Of the behavioral treatments, many of which may be of some assistance in the elderly, only sleep restriction/sleep compression therapy and multi-component cognitive-behavioral therapy have met evidence-based criteria for efficacy.

Cognitive behavioral therapy for insomnia (CBT-I)

CBT-I is recommended as the first choice for most patients with insomnia. CBT-I combines behavioral treatments, resulting in improvements lasting up to two years. Recent guidelines recommend CBT-I as the first-line therapy for insomnia in adults. Examples include:

Sleep restriction therapy: The patient is told to reduce his or her sleep/in-bed time to the average number of hours the patient has actually been able to sleep over the last two weeks (as opposed to the number of hours spent in bed (awake plus asleep)). As sleep efficiency increases, time allowed in bed is increased gradually by 15- to 20-minute increments approximately once every five days (if improvement is sustained) until the individual's optimal sleep time is obtained.

Relaxation therapy: Structured exercises designed to reduce somatic tension (eg, abdominal breathing, progressive muscle relaxation; autogenic training) and cognitive arousal (eg, guided imagery training; meditation) that may perpetuate sleep problems.

Agents evaluated in older patients:

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Class Agents Improves Strength of evidence

Considerations

Benzodiazepine receptor agonists

zolpidem (Ambien)

eszopiclone (Lunesta)

SOL

SOL, TST, WASO, sleep efficiency

low

Risks for falls and fractures, mood alteration

Short term use only

Use lower doses

Tricyclic antidepressants doxepin SOL, TST, WASO low to moderate Anticholinergic effects, sedation, and orthostatic hypotension

Orexin receptor antagonist suvorexant (Belsomra) SOL, WASO moderate Decreased alertness and increased fatigue

morning after use

Melatonin receptor agonist ramelteon SOL low Somnolence, mood alteration and dizziness

Abbr: SOL - sleep onset latency, TST - total sleep time, WASO - wake after sleep onset

Benzodiazepines and orexin receptor antagonists can be effective but have more complications and the additional risk of addiction.

Antihistamines, antidepressants including trazodone (in the absence of depression), anticonvulsants, and antipsychotics are associated with more risks than benefits in older adults.

The evidence base for exercise as a treatment for insomnia is less extensive. Despite this, there are many other reasons to encourage regular physical activity in the elderly, assuming there are no other contraindications to such activity.

There is limited research, particularly in the elderly, on complementary therapies including melatonin, L-tryptophan, valerian, chamomile, kava, and wuling. What evidence that does exist suggests that any potential benefit is equaled or exceeded by potential adverse effects, particularly in the case of valerian. They are not recommended.

Overview of Antidepressant Medications

Most antidepressants work by improving the levels of the neurotransmitters norepinephrine (NE), serotonin (5HT), and dopamine (DA). There are four major classes of antidepressants:

Class Mechanism Examples

Selective serotonin reuptake inhibitors (SSRIs)

Selectively block reuptake of serotonin, potentiating serotonin's effect on the postsynaptic neuron

Citalopram (Celexa)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Paroxetine (Paxil)

Sertraline (Zoloft)

Escitalopram (Lexapro)

Tricyclic antidepressants (TCAs) Block reuptake of norepinephrine and serotonin, potentiating their effects on the postsynaptic neuron

Nortriptyline (Pamelor)

Amitriptyline

Clomipramine (Anafranil)

Doxepin (Sinequan)

Monoamine oxidase (MAO) inhibitors Block presynaptic catabolism of norepinephrine and serotonin (rarely used today)

Phenelzine (Nardil)

Tranylcypromine (Parnate)

Serotonin and norepinephrine reuptake inhibitors

Block reuptake of norepinephrine and serotonin, increasing their concentration/availability

Venlafaxine (Effexor) and Duloxetine (Cymbalta)

Others Norepinephrine and dopamine reuptake inhibitors Bupropion (Wellbutrin)

Serotonin antagonist and reuptake inhibitors Nefazodone (Serzone) and Trazodone (Desyrel)

Norepinephrine and serotonin antagonist, antihistaminic effects Mirtazapine (Remeron)

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Serotonin partial agonist and reuptake inhibitor Vilazodone (Viibryd)

Management of Depression

When treating patients with major depression disorder, a biopsychosocial approach should be considered. "Bio" refers to pharmacotherapy; "psycho" refers to psychotherapy; and "social" refers to the identification of life stressors.

While either medication or counseling can be effective when used alone, using the two treatment modalities concurrently offers the patient the most beneficial and comprehensive therapy, and is associated with the highest rates of remission.

Medication

In a first episode of depression, it's usually recommended that the patient take the medication for nine to 12 months, as stopping any sooner runs a high risk for recurrence. Recurrent episodes of depression are treated for two to three years. With multiple recurrences and - in the elderly, who experience increased rates of recurrence - continuous therapy should be considered.

SSRIs, such as sertraline, and SNRIs are generally considered safe and effective drugs for depression. They have lower rates of side effects compared to the older tricyclics and, unlike the tricyclics, have little risk of overdose. A tricyclic such as amitriptyline would not be a first-line approach because of its multiple side effects including anticholinergic effects and sedation.

Psychotherapy

Psychotherapy, most notably cognitive behavior therapy and interpersonal therapy, have been found as effective as psychotropic medications. It can be especially useful for patients who want to avoid medication.

Exercise

Trials of mixed exercise indicated a small but statistically significant positive effect favoring exercise for the treatment of mild to moderate depression and, similarly to combining psychotherapy and medication, may have an additive effect when used in combination with other modalities.

Avoidance of other substances

Additionally, avoidance of recreational drugs and excessive alcohol use is a necessary part of any treatment regimen.

Electroconvulsive therapy (ECT)

While ECT is not an appropriate treatment for an initial episode of major depression, it is a safe and effective therapy that can be useful in patients with psychotic depression or severe nonpsychotic depression unresponsive to medications or psychotherapy and seems to improve mild cognitive impairment in depressed elderly.

Antidepressant Profiles

Effectiveness:

The selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are all equally effective in geriatric patients but recent analysis shows SNRIs have a higher rate of adverse reactions. While matching the patient's symptoms with the drug's profile, keep in mind that each patient's reaction to a medication is different and the final selection needs to be individualized.

Cost:

Cost is another strong consideration. There are now generic preparations of many antidepressants, making them more affordable.

Drug-drug interactions:

Also, antidepressants have a wide variety of drug-drug interactions, most prominently through the P450 system.

Side effects

While antidepressants are relatively safe, there are potential side effects that vary in frequency and intensity between medications and the individual patient.

Profiles

Drug Comments

Fluoxetine (Prozac)

Unusually long half life (two to four days), so effects can last for weeks after discontinuation.

Most problematic (but uncommon) side effects include agitation, motor restlessness, decreased libido in women, and insomnia.

Sertraline (Zoloft)

In addition to being a frequently used SSRI in pregnancy and breastfeeding, approved specifically for obsessive- compulsive, panic, and posttraumatic stress disorders.

More gastrointestinal side effects than the other SSRIs.

Paroxetine (Paxil)

Side effects can include significant weight gain, impotence, sedation, and constipation.

Due to its short half-life, paroxetine is most likely of all the SSRIs to cause antidepressant discontinuation syndrome.

Paxil is Pregnancy Category D

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Fluvoxamine (Luvox)

Particularly useful in obsessive-compulsive disorder.

Greater frequency of emesis compared to other SSRIs.

Citalopram (Celexa)

Most common side effects include nausea, dry mouth, and somnolence.

Maximum recommended dose: 20 mg per day for patients 60 years of age due to concerns of QT interval prolongation.

Escitalopram (Lexapro)

Approved specifically for generalized anxiety disorder.

Overall, fewer side effects than citalopram.

Adherence to Antidepressant Medication in Older Adults

Providers note that adherence to depression treatment in older adults occurs only about half the time. The reasons are understandable and include:

Inability to afford the medication

Concerns about side effects

Worry about the stigma of the diagnosis

Not understanding how to take the medication properly

The important thing is not to blame the patient. The goal is to provide education and guidance about the recommendations andallow the patient to ask questions and fully express any concerns.

Studies

Tests to Evaluate Fatigue or Depression

A complete metabolic panel screens for electrolyte, renal, and hepatic problems

A TSH can detect hypothyroidism

A CBC will show anemia and vitamin deficiencies

Clinical Reasoning

Medical Conditions Associated with Depression

A number of diseases either cause depressive symptoms or have depression as a comorbidity at higher rates than would be normally expected.

In looking for the causes and associations of depression, first consider the common conditions. Then think about the very serious diseases that you don't want to miss. Beyond that, there's a very wide range of diagnoses that can look like depression:

Hypothyroidism

About 5% of the U.S. population has hypothyroidism. Checking the level of thyroid stimulating hormone (TSH) would help make the diagnosis. Hypothyroidism can be treated with thyroid-replacement medications such as triiodothyronine (T3) and/or levothyroxine (T4). Once TSH levels are returned to the normal range, the symptoms of depression often subside.

Parkinson disease

Up to 60% of people with this disorder experience mild or moderate depressive symptoms. Although several reports have shown a link between depressive symptoms and Parkinson disease, it is unclear whether one causes the other or if both may arise from some common mechanism. A recent study has indicated that depressive symptoms are an early feature of Parkinson disease, preceding the characteristic movement problems seen in Parkinson such as tremor and rigid muscles. Therefore, people with signs of depression who start to develop movement problems should be promptly evaluated to rule out a diagnosis of Parkinson disease.

Dementia

Dementia and depression may be difficult to differentiate, as people with either disorder are frequently passive or unresponsive, and they may appear slow, confused, or forgetful. The Mini-Mental State Examination (MMSE) is useful to assess cognitive skills in people with suspected dementia. (The MMSE examines orientation, memory, and attention, as well as the ability to name objects, follow verbal and written commands, write a sentence spontaneously, and copy a complex shape.) Early and accurate diagnosis of dementia is important for patients and their families because it allows early treatment of symptoms. For people with other progressive dementia, early diagnosis may allow them to plan for the future while they can still help to make decisions. These people also may benefit from drug treatment although risk should be weighed against benefits.

References

AASMNET. The American Academy of Sleep Medicine. Are You Having Trouble Sleeping? Accessed September 27, 2023.

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APA. American Psychiatric Association. 2022. Diversity & Health Equity. Education. Mental Health Disparities: Diverse Populations . Accessed September 29, 2023.

Alonso A, Rodríguez LA, Logroscino G, Hernán MA. Use of antidepressants and the risk of Parkinson's disease: a prospective study. J Neurol Neurosurg Psychiatry. 2009;80(6):671-4.

American Psychiatric Association. Task Force on DSM-V. Diagnostic and Statistical Manual of Mental Disorders: DSM-V. Fifth edition. Arlington, VA: American Psychiatric Association; 2013.

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