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

When assessing this patient, it's important to ask questions that will help the provider understand the underlying causes and potential treatment options. Given the patient's recent loss and significant life changes, it's crucial to approach the assessment with sensitivity. Here are three questions I'd like to ask, along with their rationales:

1. Have you observed any changes in your sleep pattern, mood, or feelings since your husband passed away?

Rationale: This question allows the patient to provide insight into the nature and duration of her sleep disturbances and changes in her mood or feelings. Understanding the onset and progression of depression symptoms can related to her recent bereavement following her husband's passing.

2. Could you describe your emotions and have you ever experienced thoughts of self-harm or suicide?

Rationale: This question aims to comprehend a person's emotional state and evaluate the presence of suicidal thoughts or self-harm ideation. It's important to ask such questions without delay in treatment. Since the patient has a history of major depressive disorder (MDD), and her depression has worsened, it's crucial to explore her emotional state.

3. How have you been coping with the loss of your husband, and have you sought support or counseling to help you through this difficult time?

Rationale: Inquiring about coping strategies and support systems is essential for assessing the patient's resilience and identifying potential sources of assistance. Grief counseling or therapy can be invaluable in helping individuals navigate the complex emotions associated with loss. Additionally, it's important to assess whether the patient has been utilizing any resources to manage her depression.

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.

To gain a more comprehensive understanding of the patient's situation and evaluate her social support network, I would identify individuals in the patient's life, such as family members or close friends. Engaging in conversations with these individuals can be beneficial because they may have insights into the patient's emotional well-being and daily functioning. I would ask Questions like: “Could you please share any observations regarding alterations you may have noticed in the patient's behavior, mood, or sleep patterns following her husband's passing?” Family members and close friends are often the first to detect significant shifts in a person's behavior and emotional state. Their observations can offer valuable insights into the patient's emotional condition and the way the loss of her husband has affected her daily life.

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

In evaluating a 75-year-old patient with a chief complaint of insomnia and depression, diabetes (DM), and hypertension (HTN), a thorough assessment should include both physical exams and diagnostic tests: A physical examination should include checking blood pressure, heart rate, heart sounds, peripheral pulses, respiratory rate, and temperature. It should also involve assessing the patient's overall appearance and evaluating their general health.  In addition, assessing mental status, cognitive function, and neurological signs can help identify any neurological issues that may be contributing to sleep disturbances. Consider arranging a sleep study, also known as polysomnography (PSG). This medical test monitors various physiological functions while a person sleeps.

Diagnostic Tests include the following Blood Tests: Complete Blood Count (CBC) will check for anemia or other blood-related issues that can affect sleep and overall health; a Comprehensive Metabolic Panel (CMP), assess kidney and liver function, electrolytes, and glucose levels; The HbA1c (Glycated Hemoglobin) test can monitor her long-term blood glucose control, can provide valuable insights into her diabetes management. The results of these exams and tests will inform a comprehensive treatment plan tailored to the patient's specific needs.

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

When assessing a patient with insomnia, along with chronic medical conditions like diabetes and hypertension, this patient likely has Major Depressive Disorder (MDD). She had no history of MDD before her husband's passing, and the current worsening of her depression may be attributed to his death. Although anxiety can cause insomnia problems, MDD with Bereavement seems most likely. However, we need to ensure there aren't other underlying causes, such as sleep problems or medical issues. To do that, we should conduct thorough assessments and laboratory tests. She needs to seek help from both her regular doctor and a mental health professional to find the right treatment and support.

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.

When selecting pharmacologic agents for this 75-year-old patient, the choice of antidepressant therapy should consider pharmacokinetics and pharmacodynamics. Reduced kidney and liver function in elderly individuals can potentially affect both pharmacokinetics and pharmacodynamics.

SSRIs, such as sertraline (Zoloft) and escitalopram (Lexapro), are two preferred for elderly patients. They are generally well-tolerated and have a lower risk of certain side effects, such as sedation or anticholinergic effects, which can be problematic for older adults. Sertraline (Zoloft) 150mg once daily or Escitalopram (Lexapro) 20 mg daily would be appropriate for this patient.

The patient has been taking Sertraline (Zoloft), her start dose was 100mg daily; increase slowly, no more than a maximum Dose of 200 mg once daily; sertraline increases serotonin levels and can be effective in treating depression. Escitalopram is considered perhaps the best-tolerated SSRI, with the fewest cytochrome P450 (CYP450)-mediated drug interactions. (Stahl, 2021). Escitalopram (Lexapro) 20 mg daily is also the appropriate choice.

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?

When prescribing antidepressant therapy, it's important to consider drug contraindications and alterations. For the selected antidepressant, escitalopram (Lexapro), don't use it with MAOIs or within 14 days after stopping an MAOI to prevent serotonin syndrome. This is a contraindication due to the risk of serotonin syndrome, a potentially life-threatening condition characterized by agitation, confusion, rapid heart rate, and other symptoms. Escitalopram is primarily metabolized in the liver; it should be used with caution in patients with severe hepatic impairment or elderly with decreased liver function. In such cases, a lower initial dose and slower titration may be considered, as drug clearance may be reduced.

In all cases, ethical prescribing involves a thorough assessment of the patient's medical history, medication history, and potential contraindications. Dosing adjustments, when necessary, should be made to maximize therapeutic benefits while minimizing risks and adverse effects.

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.

In depression treatment, scheduled follow-up appointments are vital for assessing progress, managing side effects, and adjusting treatment. Common intervals are every 4 weeks. At the checkpoint, like follow-up data at weeks 4, 8, 12, etc., make treatment decisions based on the patient's response, side effects, and goals. If there's significant improvement with few side effects, stick with the current dose. If there's limited improvement or major side effects, consider increasing the dose (if not already at the maximum) or trying a different antidepressant. In cases of long-term remission with a low risk of recurrence, think about tapering or discontinuing the medication.

At Week 4 (four weeks after initiating treatment), it's the time to evaluate the patient's initial response to medication. Inquire about changes in mood, sleep patterns, energy levels, and any side effects.

At Week 8 (eight weeks after starting treatment), it's time to reassess the patient's mood and overall well-being. Keep an eye on side effects, whether they're taking the medication as prescribed, any changes in their medical conditions, and any suicidal ideation.

At Week 12 (12 weeks after starting treatment), continue monitoring the patient's mood and how they're responding to treatment. Check for any signs that their depression might be coming back or getting worse.

Ongoing Follow-up (Regularly, every 3-6 months): Continue to monitor the patient's mental health, medication adherence, and any emerging side effects. Evaluate the need for ongoing treatment.



Levenson JC, Kay DB, Buysse DJ. The pathophysiology of insomnia. Chest. 2015 Apr;147(4):1179-1192. doi: 10.1378/chest.14-1617. PMID: 25846534; PMCID: PMC4388122.

Stahl, S. M. (2021). Stahl's essential psychopharmacology: Neuroscientific basis and practical applications (5th Ed.) Cambridge University Press.

Lexapro Labeling-508; Reference ID: 4036381