By Day 6 of Week 7 Respond to at least two of

By Day 6 of Week 7

Respond to at least two of your colleagues on two different days in one of the following ways:

If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.

If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.

Colleague 1

Three Questions I Might Ask the Patient

Which other changes or symptoms have you been experiencing alongside the depressed mood and insomnia? This will identify other symptoms of depression the patient could be experiencing (Avasthi & Grover, 2018).

Did the insomnia begin before or after you started taking sertraline? Insomnia is a side effect of sertraline, which will help determine if the patient’s insomnia is related to sertraline.

How often do you experience feelings of inappropriate guilt or worthlessness? This will help establish the patient’s risk of having suicidal thoughts or ideations (Avasthi & Grover, 2018).

People in the Patient’s Life I Would Need to Speak To

I would want to get feedback from her children or the patient’s caregiver at home if she has one and asks the following:

How have the patient’s social interactions changed since she lost her husband? The question will establish if the patient’s symptoms have impacted her social functioning (Avasthi & Grover, 2018).

What difficulties does the patient encounter in performing her activities of daily living (ADL)? This will determine the impact of depression and insomnia on the patient’s level of functioning.

Which activities do the patient engage in that may put her at risk of injury? This will establish if the patient has any self-harming behaviors, which are prevalent in persons with depression.

Physical Exams and Diagnostic Tests Appropriate For the Patient

A head-to-toe physical exam would be appropriate to identify any signs of complications from diabetes and hypertension. A thyroid-stimulating hormone (TSH) test is also needed to rule out Hypothyroidism, which often presents with depression (Siniscalchi et al., 2020). Besides, a hemoglobin A1c test is appropriate to establish if the patient has achieved adequate glycemic control through the mean glycemic level. Lastly, it would be appropriate to screen for the severity of the patient’s depressive symptoms using the Patient Health Questionnaire (PHQ)-9 (Siniscalchi et al., 2020).

Differential Diagnosis

The likely diagnosis for this patient is Major depressive disorder (MDD). MDD is diagnosed based on the presence of a sad/depressed mood or loss of interest or pleasure in previously pleasurable activities (Avasthi & Grover, 2018). Other symptoms in the diagnostic criteria include changes in appetite, weight loss/gain, fatigue /low energy levels, insomnia/hypersomnia, psychomotor agitation or retardation, diminished capacity to concentrate and think, indecisiveness, feelings of guilt/worthlessness, and persistent thoughts of death or suicidal ideations (APA, 2013). The patient’s report of worsening depression, insomnia, and a history of depression makes MDD a likely diagnosis.

Pharmacologic Agents Appropriate For Antidepressant Therapy

Venlafaxine (Effexor XR) 37.5 mg PO once daily dose.

Venlafaxine is an SNRI indicated as a first-line or a second-line agent in patients who have not responded adequately to SSRIs (Gündüz et al., 2021).

Amitriptyline 10 mg per oral every bedtime.

Amitriptyline is a Tricyclic antidepressant (TCA) used in treating major depression.

Preferred Agent: Venlafaxine would be chosen over Amitriptyline owing to its strong safety profile and tolerability, which results in a high compliance rate. However, Venlafaxine has contraindications like the concomitant administration with Monoamine oxidase inhibitors (MAOIs) used in treating a psychiatric disorder (Gündüz et al., 2021).

Check Points

The patient will be followed-up after four weeks to assess the impact of medication in alleviating depression and insomnia and associated drug side effects. If the patient demonstrates partial improvement of symptoms with no side effects, the Venlafaxine dose will be increased to 75 mg QD to promote complete remission of symptoms.

Colleague 2

A 75-year-old female presented to the office with c/o insomnia. The patient’s husband passed about 10 months ago and since then she states her depression has gotten worse, along with her sleep habits. No previous history of depression before her husband’s death. PHM: DM, HTN, and MDD.

Three Questions

How many hours a night do you sleep?

How long have you been not been able to sleep?

What does your day consist of including food and liquid intake and daily activities?

The three above questions would help this clinician understand if the patient’s disruption in sleep or insomnia is contributing to her increased depressive symptoms or if her medication is causing her to have the side effect of insomnia. According to Webb et al, (2018), individuals with late-life depression are at a public health risk as evidence suggests that “sleep disturbance plays a role in depression and risk for suicidal behavior” (par.1).

Support System.

As a clinician, it is important to explore barriers to treatment adherence and identify opportunities for adherence strategies (Traeger et al, 2016).

The following individuals would assist in the assessment of the patient and her current chief complaint:

Children: Have you noticed any changes in your mother’s daily routines? Do you notice any changes in her behaviors? Does she have assistance with medication coverage and is she able to manage her medication as prescribed? Does your mother visit with her friends or belong to any social groups?

Primary Care Physician: Are there any new medical health conditions? Has the patient been compliant with previous treatment plans? Has there been any physical or mental health concerns observed during the examination since the patient’s husband expired?

Physical and Diagnostic Test

The recommendation for depression in older adults is to utilize second-generation antidepressants and non-pharmacologic interventions (apa.org, 2019). According to the treatment algorithm for insomnia, the three non-pharmacological interventions include cognitive behavioral therapy, sleep hygiene, and sleep study (Puzantian & Carlat, 2020). Assessing the patient’s sleep hygiene during the examination and ordering a diagnostic sleep study allows this clinician to form a differential diagnosis.

Differential Diagnosis

A differential diagnosis for insomnia relating to this patient would be depression. As mentioned previously the patient’s husband expired less than a year ago and the patient has expressed an increase in depression symptoms. According to Papadakis et al., (2022), depression correlates with fragmented sleep, decreased total sleep time, and a shift in REM activity.

Pharmacological Treatment

The two pharmacological agents that would be appropriate for the patient’s antidepressant therapy would include increasing the Sertraline to 150 mg PO daily and adding Trazadone to 25 mg PO oral at bedtime. Increasing the Sertraline to the next dose allows the patient to reach optimum benefit by increasing the dosage at a slow titrate to reduce the risk of side effects (apa.org). Hamilton (2019), also mentions that the therapeutic dose for Sertraline is in the range of 50 to 200 mg/day with a 200 mg max dose. The patient is not reporting any other side effects indicating a need to change drug class. Sertraline would need to be titrated if the patient had a hepatic impairment and will need to be readdressed if the patient experiences a cardiac arrhythmia causing the need for Warfarin; as this medication is contraindicated with Sertraline use.

Trazadone is also an antidepressant known for its serotonin receptor antagonist effects. Keeping Trazadone at a low dose of 25 mg at bedtime allows for the patient to utilize this medication for the treatment of insomnia, which could be secondary to antidepressant use (Fava & Papakostas, 2016). The most common side effect of Trazadone is sedation, orthostatic hypotension, and headaches (Fava & Papakostas, 2016). This will require this clinician to provide education to the patient and family members to recognize any signs or symptoms that warrant medical advice. The case study also stated the patient had a PMH of HTN, which Trazadone should be used with caution with known cardiac disease. This will need to be taken into account when prescribing the length of treatment. Per the treatment algorithm for Insomnia as noted by Puzantian and Carlat (2020), Trazadone is a medication of choice for comorbidity of depression and at a low dose, is recognized as a non-addictive option for insomnia.

Once the treatment plan has been explained and agreed upon by the patient and clinician, the patient will be required to follow up in 4 weeks. This follow-up will allow the drug Sertraline to reach its new therapeutic dose, and address any concerns about the patient’s previous complaint of insomnia. If there are no reported side effects and the patient has improved in her sleeping habits, this would allow for the medication Trazadone to be tapered, while also addressing the full effect from her current dose of Sertraline.