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Depression Case Study
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
By Day 3 of Week 7
Post a response to each of the following:
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
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Depression Case Study: An elderly widow who just lost her spouse.
Questions to the Patient
The first question I would ask the patient is her psychotropic medication compliance because it is necessary for optimal outcomes in patients with a history of depression. Partial or complete non-adherence is a risk factor for worsening symptoms. The loss of her husband is a major stressful event that may have triggered a depressive episode. Coupled with the possibility of non-adherence, it could result in worsening depression and insomnia.
The second question would be to understand her coping mechanisms after the loss of her husband. The question would help focus on any bad habits like increased coffee intake, alcohol, or substance abuse. The existence of alcohol or drug abuse could help determine the reason for the patient’s symptoms.
The third question to the patient would be whether she frequently checks her blood sugar levels. Poor diabetes control results in hypoglycemia or hyperglycemia. The symptoms for either could prompt symptoms that mimic those of depression.
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Questions to the Family/Caretaker
The woman is an older adult at 75 years old. Based on her existing illnesses, husband's demise, and the risk for cognitive impairment with aging, I would be interested in understanding her source of support at home. An interview with her child or a caretaker would be an opportunity to obtain valuable information about the patients functioning at home and compliance with her treatment plan.
Diagnostic Tests
The co-existence of depression and diabetes is a clinical challenge since both conditions interact towards poor health outcomes. Since the patient has a past medical history of diabetes, I would request for HBA1c levels to provide information about the patient's blood sugar control for the past three months (Holt et al., 2014). It would be a critical test in the diagnosis and in providing an individualized plan of care for the patient.
The US Preventative Task Force (USPTF) recommends that adults aged 60 years and above get regular screening for depression. I would screen the patient for depression using the Patient Health Questionnaire-2 (PHQ-2). It serves as an appropriate tool for assessing the 2 cardinal symptoms of depression- a depressed mood and anhedonia (Vieira et al., 2014). A score of 2 or 3 and above would mean referring the patient for further psychiatric evaluation.
Differential Diagnosis
A differential diagnosis for the patient is Alzheimer’s disease. It is a neurodegenerative illness that results in a continuous cognitive decline, behavioral, and social skills that interfere with the patient’s ability to function effectively (Garcez et al., 2015). It is a possibility because elevated stress exacerbates Alzheimer's disease resulting in a rapid decline in cognitive function. The loss of the patient's husband could signify significant stress and worsening depressive symptoms.
Possible Treatment Approach
The choice of anti-depressants in older adults is based on the side-effect profile and a lower risk for drug-drug interactions. The patient is already on sertraline 100 mg, a selective serotonin reuptake inhibitor. It has been effective in achieving symptom remission with the patient reporting no depressive symptoms before the death of her husband. However, the event resulted in a depression relapse with a need for reviewing her medication. My choice for the patient is augmenting the Sertraline with Trazodone 100 mg a day, a serotonin 2 antagonist. It works by blocking of the 5-HT2A, Histamine H1, and alpha receptors thus producing a hypnotic effect (Stahl, 2020). Its low potency on the serotonin re-uptake pump can help in alleviating the patient’s depressive symptoms in combination with the Sertraline 100 mg/day (Stahl, 2020). Moreover, it does not cause tolerance or dependence and may be discontinued safely if the depressive/anxiety symptoms are in remission.
Bupropion, a dopamine re-uptake inhibitor is also a possible augmenting agent in a common combination called “Well-loft.” However, a combination of anti-depressants increases the possibility of suicidal ideations (Patel et al., 2016). Therefore, adding Trazodone 100 mg/day would be a better approach to the patient than using Bupropion. Follow-up in 4 weeks can help evaluate the efficacy of the approach for more individualized care.
References
Garcez, M. L., Falchetti, A. C. B., Mina, F., & Budni, J. (2015). Alzheimer s disease associated with psychiatric comorbidities. Anais da Academia Brasileira de Ciências, 87(2), 1461-1473.
Holt, R. I., De Groot, M., & Golden, S. H. (2014). Diabetes and depression. Current diabetes reports, 14(6), 1-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4476048/
Patel, K., Allen, S., Haque, M. N., Angelescu, I., Baumeister, D., & Tracy, D. K. (2016). Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant. Therapeutic advances in psychopharmacology, 6(2), 99-144.
Stahl, S. M. (2020). Stahl online. https://stahlonline.cambridge.org/prescribers_drug.jsf?page=9781108926010c134.html.therapeutics&name=TRAZODONE&title=Therapeutics#IDXl-tgt-2377
Vieira, E. R., Brown, E., & Raue, P. (2014). Depression in older adults: screening and referral. Journal of Geriatric Physical Therapy, 37(1), 24-30.
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