Differential diagnosis for the patient presenting with insomnia and worsening depression following the loss of her spouse includes

QUESTION

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 

• 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 ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
• 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.

ANSWER

Differential diagnosis for the patient presenting with insomnia and worsening depression following the loss of her spouse includes

Major depressive disorder (MDD) with melancholic features: This is the most likely diagnosis given the patient’s history of depression worsening after her husband’s death. The symptoms of insomnia and worsening depression are consistent with MDD, and the absence of suicidal ideations is an important factor in differentiating it from other conditions.

Adjustment disorder with depressed mood: The loss of her spouse may have triggered an adjustment disorder, characterized by a maladaptive response to a significant life event. However, given the duration of symptoms and the absence of improvement over time, MDD is a more probable diagnosis.

Pharmacologic agents for the patient’s antidepressant therapy

Selective serotonin reuptake inhibitors (SSRIs): SSRIs, such as sertraline, are commonly used as first-line treatment for MDD. The initial dosing for sertraline in adults is 50 mg daily, which can be increased to 100-200 mg based on response and tolerability.

Serotonin-norepinephrine reuptake inhibitors (SNRIs): SNRIs, such as venlafaxine, are another class of antidepressants that can be considered. The initial dosing for venlafaxine extended-release in adults is 75 mg daily, which can be titrated up to a maximum dose of 225 mg based on response and tolerability.

Rationale for choosing an SSRI over an SNRI: SSRI medications, like sertraline, are often preferred as initial treatment options due to their relatively favorable side effect profile and established efficacy in the treatment of MDD. SNRIs may be considered as an alternative if the patient does not respond to or tolerate the SSRI, or if there are specific symptoms (such as significant fatigue) that may benefit from the additional noradrenergic effects of the SNRI.

Contraindications or alterations in dosing for sertraline

Contraindication in patients taking monoamine oxidase inhibitors (MAOIs) or within 14 days of discontinuing MAOIs, as it can result in a potentially life-threatening serotonin syndrome.

Dosing alterations may be needed in patients with hepatic impairment, as sertraline is metabolized by the liver. Lower starting doses and slower titration may be considered in these individuals to minimize the risk of adverse effects.

Checkpoints and therapeutic changes

It is important to closely monitor the patient’s response to treatment and adjust therapy as needed. Follow-up at week 4, 8, and 12 can be utilized to assess the patient’s symptomatology, side effects, and treatment adherence. Based on possible outcomes, therapeutic changes that may be considered include dose adjustments, switching to an alternative antidepressant, or adding adjunctive therapies such as psychotherapy if the patient’s symptoms are not adequately controlled.

In conclusion, the most likely diagnosis for the patient is major depressive disorder with melancholic features. Sertraline, an SSRI, is a suitable pharmacologic agent for antidepressant therapy. Contraindications and dosing alterations should be considered based on ethical prescribing guidelines and individual patient factors. Regular follow-up and therapeutic adjustments are essential to optimize treatment outcomes.