An 82-year-old male resident of a nursing home has developed symptoms of depression including withdrawal and sadness. The staff also reports that he doesn’t want to leave his room, and often expresses a desire to stay in bed all day. After performing an appropriate evaluation and recommending nonpharmacologic interventions, you also decide that pharmacologic treatment is indicated.
Which one of the following would be the most appropriate antidepressant for this patient?
Correct Answer D:
Amitriptyline, doxepin, MAO inhibitors, and clomipramine should be avoided in nursing-home patients. SSRIs are the most appropriate first-line pharmacologic treatment for depression in nursing-home residents. Other classes of non tricyclic antidepressant may be effective and appropriate, but the evidence for this is not as good as the evidence for SSRIs.
The husband and daughter of a 65-year-old female report recent changes in her behavior, including decreased energy, lack of motivation, difficulty making decisions, decreased appetite, and insomnia of 4 weeks’ duration. She turned down visits of her friends and didn't go to her usual bridge and bingo game nights. The patient is not on any new medication, and has no previous medical problems. Over the past 2 days, she has become concerned about memory loss for both recent and remote events.
This patient most likely has:
Correct Answer A:
The diagnosis of depression requires the presence of at least five of the following: depressed mood, sleep disturbance, lack of interest or pleasure in activities, guilt and feelings of worthlessness, lack of energy, loss of concentration and difficulty making decisions, anorexia or weight loss, psychomotor agitation or retardation, and suicidal ideation. The symptoms must be present nearly every day during a 2-week period. Because dementia may cause similar symptoms, distinguishing between the two is important. Dementia is insidious, with a long duration of symptoms including fluctuating mood and memory impairment for recent events. Memory loss often precedes mood changes. Organic problems such as brain tumor, hypoglycemia, and myocardial infarction may cause similar symptoms, but are far less likely to be the cause.
An initial episode of depression has responded to pharmacologic treatment.
Treatment should be continued for a minimum of:
Correct Answer C:
Current guidelines suggest that patients who respond to antidepressant medication during a single episode of depression should continue to take the drug, at the same dose, for 9 months (8 to 12 weeks to attain remission, then 6 months for maintenance).
Therapy should be continued for at least 2 years for older patients; those with psychotic features; and those whose episodes are recurrent, frequent, difficult to treat, or severe. When antidepressant medication is stopped, patients should be cautioned about discontinuation syndrome, which includes such symptoms as insomnia, nausea, paresthesia, and hyperarousal; these symptoms can be reduced by tapering the dose of antidepressant rather than stopping it abruptly.
A 25 year old male visits your office for follow-up 3 weeks after beginning fluoxetine (Prozac) for newly diagnosed major depression. He has experienced gastrointestinal discomfort, increased agitation, worsening insomnia, and sexual dysfunction since beginning the drug. Together you agree to discontinue fluoxetine and begin a different medication.
Which one of the following would be the best choice to avoid agitation and sexual dysfunction?
Many patients stop taking antidepressants within the first month of therapy, often citing side effects as the reason. Fluoxetine, an SSRI, is frequently associated with gastrointestinal irritation, sexual side effects, and agitation. Sertraline is an SSRI with a similar side-effect profile. Bupropion does not have the sexual side effects of the SSRIs but can cause significant agitation. Clonazepam is a benzodiazepine and likely would not cause many of this patient’s side effects, but is not appropriate as the primary treatment for major depression. The mechanism of action for venlafaxine includes both serotonin and epinephrine reuptake inhibition, and it can cause some of the same symptoms as the SSRIs. Mirtazapine, however, would help this patient sleep, usually does not cause appetite suppression, and infrequently causes sexual disturbance.
A 50-year-old female with a history of paroxysmal atrial fibrillation has been successfully treated for depression with sertraline. However, she has persistent insomnia, and a 10-day trial of zolpidem has yielded minimal improvement.
The most appropriate addition to her current medication would be:
Trazodone has been found useful for its sedative and hypnotic effects, and is often used in combination with another antidepressant.
→ Benzodiazepines are not recommended for long-term use.
→ Zaleplon is more short-acting than zolpiden and therefore would not be more effective.
→ Amitriptyline could be used for its antidepressant and sedative effects, but its chronotropic side effects make it less preferable for someone with a disposition to cardiac arrhythmia.
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