Jeannie Higgin
Week 7 DB JH
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
- Do you prefer to stay home instead of going out? This question recognizes that isolation and withdrawal are common signs of depression. Mental health professionals rely on several screening tools to diagnose depression accurately. The Geriatric Depression Scale includes information that helps identify a common symptom of depression, especially in the elderly (“5 Questions Doctors Ask When Screening for Depression. Here’s a peek at the questions they ask – so you can assess your own risk. Chris Iliades, MD By Chris Iliades, MD Medically reviewed by Niya Jones, MD, MPH Reviewed: June 22, 2011,” n.d).
- How often do you feel down, depressed, or hopeless? Over two weeks, if a person feels down more than half the day or mostly every day over the past two weeks suggests depression and a need for treatment to relieve symptoms (“5 Questions Doctors Ask When Screening for Depression. Mental health professionals rely on some screening tools to diagnose depression accurately. Here’s a peek at the questions they ask – so you can assess your own risk. Chris Iliades, MD By Chris Iliades, MD Medically reviewed by Niya Jones, MD, MPH Reviewed: June 22, 2011,” n.d.).
- Do you have any thoughts of suicide? Suicide rates in the elderly are high (“Geriatric depression: The use of antidepressants in the elderly,” n.d.). The Hamilton Depression Rating Scale (HDRS) helps mental health providers rate the severity of depression and suicidal thoughts, which are harmful (Hamilton, 1960).
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.
It would be prudent to speak to friends, family, and any caregivers associated with the patient to assess the patient’s situation further. A question to ask these people is, have you noticed a change in her energy? This question is relevant because a decline in energy is a common sign of depression (Hamilton, 1960). The Beck Depression Inventory helps identify depression and patients who meet clinical diagnostic criteria (“Beck Depression Inventory (BDI),” n.d.). Another question to ask these people is, has she complained of nightly difficulty falling asleep? This question is relevant as studies show that insomnia can lead to depression ( Staner, 2010). This patient is diagnosed with Major Depressive Disorder, and treating insomnia may help decrease symptoms of depression once it is addressed. The research found that fifty percent of adults with insomnia have a mental health issue, and ninety percent of adults with depression experienced sleep problems (Abbott & The Conversation, n.d.).
Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
During a physical exam and diagnostic testing, the provider should check for pallor associated with anemia, lymphadenopathy related to cancer, and fatigue leading to decreased energy, thyroid disease, and cardiorespiratory disease as this could be an underlying cause related to sleep disturbance (Koshy & Majeed, 2008). Thyroid problems can lead to sleep issues (“Could your thyroid be causing sleep problems?” 2020). If her thyroid test results are abnormal the patient can receive treatment if there is an imbalance. Hyperthyroidism and hypothyroidism overlap with sleep conditions (Green et al., 2021). A study assessed one hundred thirty-seven patients with Graves disease and the most common cause of hyperthyroidism, the report showed sixty-six-point four percent of participants had difficulty falling asleep (Green et al., 2021).
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
A differential diagnosis can include obesity as a factor for sleep-disordered breathing (Peppard et al., 2013). A differential diagnosis could be sleep apnea related to obesity. The patient is eighty-eight kilograms which is one hundred ninety-four pounds; obesity is considered a possible issue, and sleep apnea may be an underlying cause of her inability to stay asleep related to repeated waking during the night. Studies have shown a high prevalence of insomnia in patients diagnosed with obstructive sleep apnea ( Benetó et al., 2009). A retrospective study showed that obstructive sleep apnea -insomnia association refers to patients presenting with obstructive sleep apnea and insomnia; the study estimated that fifty percent of patients presenting had obstructive sleep apnea (Benetó et al., 2009). A sleep study test may help rule out sleep apnea and the need for treatment.
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.
Celexa ( Citalopram) has a starting dose of ten milligrams, and the average dose is twenty to forty milligrams (“Geriatric depression: The use of antidepressants in the elderly,” n.d.). When a provider has selected an antidepressant for an older person, the starting dose should be low to minimize side effects (“Geriatric depression: The use of antidepressants in the elderly,” n.d.).The mechanism of action results in inhibition of the central nervous system neuronal reuptake of serotonin, inhibiting serotonin reuptake in the synaptic cleft (“Citalopram,” n.d.). It is absorbed from the gastrointestinal tract with plasma concentrations within four hours of a single oral dose with a bioavailability of eight percent after oral administration (“Citalopram,” n.d.). Pharmacokinetics is concerned with the movement of drugs within the body like absorption, distribution, excretion, and localization in the tissues (“NCI Dictionary of cancer terms,” n.d.).
Celexa is a serotonin reuptake inhibitor and works by increasing serotonin levels in the brain (“Citalopram,” n.d.). As far as pharmacodynamics, selective serotonin reuptake inhibitors relieve or manage symptoms of depression (“Citalopram,” n.d.). Behavioral and neuropsychological effects of serotonin include regulation of mood, perception, reward, anger, aggression, appetite, and memory are some examples (“Citalopram,” n.d.). The complete response takes eight to twelve weeks after initiation (“Citalopram,” n.d.).
Remeron (Mirtazapine) has a starting dose of fifteen and an average dose of thirty to forty-five milligrams (“Geriatric depression: The use of antidepressants in the elderly,” n.d.). The pharmacokinetics of Remeron include it being a noradrenergic and specific serotonergic antidepressant (Timmer et al., 2000). It has rapid absorption in the gastrointestinal tract after a single oral dose (Timmer et al., 2000). The bioavailability is fifty percent because of the wall of the gut and hepatic first-pass (Timmer et al., 2000). The pharmacokinetics are dependent on age and gender (Timmer et al., 2000). The elderly show higher plasma concentration than males and young adults (Timmer et al., 2000).
A randomized, double-blind, multicenter eight-week study of patients with major depressive episodes showed improvement in sleep disturbances, anxiety, and quality of life (Leinonen et al., 1999). However, there was a more significant favorable change with mirtazapine use (Leinonen et al., 1999). Mirtazapine is considered clinically superior among the two proven antidepressants (Leinonen et al., 1999). Mirtazapine shows faster sleep improvement and sleep quality, and Mirtazapine was more effective than Celexa after two weeks of treatment (Leinonen et al., 1999). The findings showed a faster onset of efficacy of Mirtazapine over Celexa (Leinonen et al., 1999). Considering that this patient has sleep disturbance and significant depression, Mirtazapine would be chosen according to research findings. According to research found, both Remeron and Celexa be efficacious in elderly patients being treated for major depression without psychotic features (“Geriatric depression: The use of antidepressants in the elderly,” n.d.).
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?
Remeron has a side effect of weight gain in decision making, and this patient already has a weight issue. Ethically prescribing this medication, the provider would have to think if the patient would be motivated to change diet and exercise to decrease weight gain as she is already dealing with depression; motivation could be an issue (Timmer et al., 2000). Once an antidepressant is chosen for an elderly patient, the starting dose should be half that prescribed for a younger adult (“Geriatric depression: The use of antidepressants in the elderly,” n.d.). Suicide risk is associated with Remeron the patient should be monitored (“Side effects of Remeron (Mirtazapine), warnings, uses,” n.d.). Dosages are increased slowly over two weeks (“Side effects of Remeron (Mirtazapine), warnings, uses,” n.d.). Remeron should not be used with monoamine oxidase inhibitors (MAOIs) (Ogbru, n.d.). Monoamine oxidase inhibitors interact with certain foods and drugs and elevate serotonin levels (Ogbru, n.d.). At least fourteen days should be allowed to have the medication work, before stopping Remeron (“Remeron (Mirtazapine): Uses, dosage, side effects, interactions, warning,” n.d.). At least fourteen days should be between stopping Remeron and starting an MAOI because of contraindication of increased serotonin syndrome risk (“Remeron (Mirtazapine): Uses, dosage, side effects, interactions, warning,” n.d.).
Include any “checkpoints†(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.
Remeron should be taken at bedtime. It can cause drowsiness (“Side effects of Remeron (Mirtazapine), warnings, uses,” n.d.). Follow-up with dose change should be no less than one to two weeks to allow a therapeutic response (“Remeron (Mirtazapine): Uses, dosage, side effects, interactions, warning,” n.d.). Providers should be aware that plasma Remeron clearance is reduced in elderly patients, and Remeron levels may be increased in elderly patients (“Remeron (Mirtazapine): Uses, dosage, side effects, interactions, warning,” n.d.).
References
5 Questions Doctors Ask When Screening for Depression Mental health professionals rely on a number of screening tools to accurately diagnose depression. Here’s a peek at the questions they ask — so you can assess your own risk. Chris Iliades, MD By Chris Iliades, MD Medically Reviewed by Niya Jones, MD, MPH Reviewed: June 22, 2011. (n.d.).
Abbott, J., & The Conversation. (n.d.). What’s the link between insomnia and mental illness? ScienceAlert. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness
Beck Depression Inventory (BDI). (n.d.). https://www.apa.org. https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/beck-depression
Benetó, A., Gomez-Siurana, E., & Rubio-Sanchez, P. (2009). Comorbidity between sleep apnea and insomnia. Sleep Medicine Reviews, 13(4), 287-293. https://doi.org/10.1016/j.smrv.2008.09.006
Citalopram. (n.d.). https://go.drugbank.com/drugs/DB00215
Could your thyroid be causing sleep problems? (2020, December 11). Sleep Foundation. https://www.sleepfoundation.org/physical-health/thyroid-issues-and-sleep
Geriatric depression: The use of antidepressants in the elderly. (n.d.). British Columbia Medical Journal. https://bcmj.org/articles/geriatric-depression-use-antidepressants-elderly
Green, M. E., Bernet, V., & Cheung, J. (2021). Thyroid dysfunction and sleep disorders. Frontiers in Endocrinology, 12. https://doi.org/10.3389/fendo.2021.725829
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery & Psychiatry, 23(1), 56-62. https://doi.org/10.1136/jnnp.23.1.56
Koshy, E., & Majeed