An Elderly Widow Who Just Lost Her Spouse Case Discussion

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Introduction:

In this case study, a 75-year-old widow presented to the primary care office with complaints of insomnia and worsening depression since her husband’s demise ten months ago. The patient has a past medical history of diabetes, hypertension, and major depressive disorder (MDD) and is currently on metformin, januvia, losartan, HCTZ, and sertraline. In this discussion, we will outline the questions we might ask the patient to assess her health needs, identify people in her life we would need to speak to, explain the physical exams, and diagnostic tests that would be appropriate and suggest differential diagnosis for the patient. Furthermore, we will list pharmacological agents recommended for antidepressant therapy and the dosing and any contraindications. Finally, we will outline any check-points and follow-up data necessary to make therapeutic changes based on possible outcomes.

Answer:

1. List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.

a) How has your sleep been disturbed since your husband’s death ten months ago? – This question would provide insights into the nature of disturbed sleep and the timeframe since the patient’s decreased sleep hygiene.

b) Do you feel like you have lost pleasure doing things that used to make you happy? – This question would provide information on any loss of interest in usual activities and emotional numbness, which are common in depressive disorders.

c) Do you have a history of any major personal losses? – This question could help identify any other factors contributing to the patient’s worsening MDD and insomnia.

2. 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.

We would need to speak to the patient’s family and friends who have seen a noticeable change in her since her husband’s death. We would ask if they have observed any concerning behaviors such as social isolation, loss of interest in usual activities, and change in sleep habits.

3. Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.

A complete physical examination, including thyroid function tests and serum glucose level examination, would be appropriate to assess whether medical conditions, such as hyperthyroidism and diabetes, are contributing to the patient’s insomnia and depression. Further assessments may include a depressive disorder diagnosis based on DSM-V criteria and a polysomnogram to check for any sleep disorders.

4. List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.

The patient’s most likely diagnosis is major depressive disorder (MDD) with insomnia. Other possible differential diagnoses include grief, adjustment disorder, and bipolar disorder. However, given the patient’s prolonged symptoms and more extended timeframe since her husband’s death, MDD with insomnia is the most likely diagnosis.

5. 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.

Two pharmacological agents that would be appropriate for the patient are SSRIs, such as sertraline (current medication), and SNRIs, such as venlafaxine extended-release (225mg/day). Although both classes of medications raise serotonin levels in the brain, SNRIs also increase norepinephrine levels, which may provide additional benefits in treating insomnia symptoms. Hence, venlafaxine extended-release may be preferred for antidepressant therapy over sertraline.

6. 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?

There are no significant ethnically related contraindications or dosing alterations for venlafaxine. However, variations in cytochrome P450 (CYP) pathways that metabolize venlafaxine may occur in some ethnicities, leading to differences in drug response and potential drug-drug interactions.

7. 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.

Follow-up visits with the patient will occur after four weeks to assess any adverse effects, therapeutic efficacy, and medication compliance. Depending on the patient’s response, the dosage can be adjusted to target an optimal response. Additionally, therapy changes may be considered if the patient does not respond to venlafaxine or experiences adverse effects. Such therapeutic changes may include referral to psychotherapy, augmentation of psychopharmacological treatment, or switching to another antidepressant.