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 kgCurrent height: 64 inchesTemp: 98.6 degrees FBP: 132/86
Three Questions
The following questions I would ask this patient, consist of gathering more data to make
an appropriate treatment plan. I would ask for any current allergies to explore possibilities of
poor medication prescribing. Afterwards, I would ask her to describe her sleep pattern (ex. Do
you have trouble staying asleep or falling asleep? And how many hours of sleep do you get in a
night?). This will help by determining appropriate medication management for insomnia due to
symptoms provided. Then I would ask her to describe her mood related to depression (ex.
Motivation, drive, and if sleep is interfering with her general lifestyle). Finding additional issues
will help identify issues that contributed to the Beck Depression Inventory (BDI). The BDI has
been used to measure behavioral manifestations related to the severity of depression for ages 13
to 80 and has been used internationally (American Psychological Association, 2005).
Patient Relationships
If this patient has children, grandchildren or general family members, questions towards
her family can be essential to evaluate changes in mood. Asking questions with family who have
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a consistent relationship like have you seen a difference in mood or is there any concerns about
this patient’s sleeping habits are a few questions that can be asked. Also, follow-up with this
patient’s primary care provider to ask for further health history would show a thorough
investigation related to mood, weight gain, and management of her diabetes. Evaluation of
weight gain, blood sugars, and blood pressure can reveal decline in or consistent self-care. If
issues arise, directing patients to reliable, accessible information is a positive step to ensure
effective patient-centered, evidence-informed care to address gaps to support positive goals
(Pilkington, & Wieland, 2020).
Exams and Testing
Health history that can be provided towards this patient’s management of diabetes
can reveal compliance and self-management of this patient’s health. Then BDI will create
a patient centered questionnaire asking about mood, drive, appetite, and etc. This scale
ranges from 1-60 with indicators of 1-10 being normal, 11-16 mild mood disturbance, 17-
20 borderline clinical depression, 21-30 moderate depression, 31-40 severe depression,
and over 40 extreme depressions. (Beck's Depression Inventory, n.d). To appropriately
treat this patient, BDI will give essential insight to symptoms related to this patient’s
status of depression.
Differential Diagnosis
Cross-sectional studies show a strong relationship between symptoms of depression and
insomnia due to sleep strongly influencing both development and trajectory of depression
impacting frequency severity and duration (Franzen, & Buysse, 2008). Although there is a close
relationship, a possible differential diagnosis of bipolar could be indicated. Bipolar disorder has
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shown alternating periods of elevated and depressed mood that can cause sleep disturbances
(Gold, & Sylvia, 2016). Possible indications of bipolar disorder being a differential diagnosis can
be implied to mania causing insomnia experienced. Evaluation of behaviors such as impulsivity
and labile mood can help identify trademark signs of mania.
Pharmacological Decisions
Trazodone (Desyrel) has been found to have low risks of side effects such as weight gain,
sexual drive changes, and anticholinergic effects (such as constipation, urinary retention, dry
mouth) and helpful for patients whose symptoms of depression include insomnia (Cuomo, et. al.,
2019). The unique property of trazodone is the inhibition of SERT, 5-HT2A, and 5-HT2c
receptors avoiding issues of sexual dysfunction, insomnia and anxiety that presents with SSRIs,
and SNRIs therapy. (Shin, J. J., & Saadabadi, A., 2020).
The unique property of trazodone, where it simultaneously inhibits SERT, 5-HT2A, and
5-HT2C receptors, is that it avoids the issue of sexual dysfunction, insomnia, and anxiety that
commonly presents with SSRIs and SNRIs therapy. Trazodone reduces levels of
neurotransmitters associated with arousal effects, such as serotonin, noradrenaline, dopamine,
acetylcholine, and histamine.
Mirtazapine (Remeron) is a noradrenergic and specific serotonergic antidepressant and is
commonly prescribed in the elderly population with insomnia and low weight due to the sedating
and weight gain effects (Guzman, 2019). Considering this patient’s current weight at 88kg and
64 inches, weight gain will not be beneficial for this patient. Therefore, Trazadone rather than
Mirtazapine can yield a better outcome for management of overall health. Increase in weight can
result in further issues with diabetes, blood pressure, and self-care.
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Contraindications
Trazadone has not shown any major side effects with Metformin, Januvia, Losartan, or
HCTZ. Sertraline and Trazadone can increase the risk of a rare but serious condition called
serotonin syndrome, resulting in symptoms such as confusion, hallucinations, seizure, extreme
changes in blood pressure, increased heart rage, fever, excessive sweating, shivering, or shaking,
blurred vision, muscles stiffness, tremor, incoordination, stomach cramp, nausea, vomiting, and
diarrhea (Drugs.com, 2021). Serious issues can result in coma or death causing an ethical
dilemma related to sleep and depression. Possible education of discontinuation of sertraline may
be needed if insomnia is the primary issue related to this patient. Further discussion would be
required to identify alternatives for sertraline.
References
American Psychological Association. (2005). Depression Assessment Instruments. American Psychological Association. https://www.apa.org/depression-guideline/assessment.
Beck's Depression Inventory. (n.d.). https://www.ismanet.org/doctoryourspirit/pdfs/Beck-Depression-Inventory-BDI.pdf.
Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Di Sciascio, G., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (2019). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: pharmacology and clinical practice. Rivista di psichiatria, 54(4), 137–149. https://doi.org/10.1708/3202.31796
Franzen, P. L., & Buysse, D. J. (2008, December 1). Sleep disturbances and depression: risk relationships for subsequent depression and therapeutic implications. Dialogues in ClinicalNeuroscience. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3108260/.
Gold, A. K., & Sylvia, L. G. (2016). The role of sleep in bipolar disorder. Nature and science of sleep, 8, 207–214. https://doi.org/10.2147/NSS.S85754
Guzman, F. (2019). Psychopharmacology Institute. https://psychopharmacologyinstitute.com/publication/mirtazapine-essentials-moa-indications-adverse-effects-pharmacokinetics-and-dosing-2222.
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Pilkington, K., & Wieland, L. S. (2020). Self-care for anxiety and depression: a comparison of evidence from Cochrane reviews and practice to inform decision-making and priority-setting. BMC complementary medicine and therapies, 20(1), 247. https://doi.org/10.1186/s12906-020-03038-8
Shin, J. J., & Saadabadi, A. (2020, May 28). Trazodone. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK470560/.
Trazodone and Zoloft Drug Interactions. Drugs.com. (2021). https://www.drugs.com/drug-interactions/trazodone-with-zoloft-2228-0-2057-1348.html.
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