Case: An elderly widow who just lost her spouse. Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:

 Metformin 500mg BID  Januvia 100mg daily  Losartan 100mg daily  HCTZ 25mg daily  Sertraline 100mg daily

Current weight: 88 kgCurrent height: 64 inchesTemp: 98.6 degrees FBP: 132/86

Three Questions

The following questions I would ask this patient, consist of gathering more data to make

an appropriate treatment plan. I would ask for any current allergies to explore possibilities of

poor medication prescribing. Afterwards, I would ask her to describe her sleep pattern (ex. Do

you have trouble staying asleep or falling asleep? And how many hours of sleep do you get in a

night?). This will help by determining appropriate medication management for insomnia due to

symptoms provided. Then I would ask her to describe her mood related to depression (ex.

Motivation, drive, and if sleep is interfering with her general lifestyle). Finding additional issues

will help identify issues that contributed to the Beck Depression Inventory (BDI). The BDI has

been used to measure behavioral manifestations related to the severity of depression for ages 13

to 80 and has been used internationally (American Psychological Association, 2005).

Patient Relationships

If this patient has children, grandchildren or general family members, questions towards

her family can be essential to evaluate changes in mood. Asking questions with family who have

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a consistent relationship like have you seen a difference in mood or is there any concerns about

this patient’s sleeping habits are a few questions that can be asked. Also, follow-up with this

patient’s primary care provider to ask for further health history would show a thorough

investigation related to mood, weight gain, and management of her diabetes. Evaluation of

weight gain, blood sugars, and blood pressure can reveal decline in or consistent self-care. If

issues arise, directing patients to reliable, accessible information is a positive step to ensure

effective patient-centered, evidence-informed care to address gaps to support positive goals

(Pilkington, & Wieland, 2020).

Exams and Testing

Health history that can be provided towards this patient’s management of diabetes

can reveal compliance and self-management of this patient’s health. Then BDI will create

a patient centered questionnaire asking about mood, drive, appetite, and etc. This scale

ranges from 1-60 with indicators of 1-10 being normal, 11-16 mild mood disturbance, 17-

20 borderline clinical depression, 21-30 moderate depression, 31-40 severe depression,

and over 40 extreme depressions. (Beck's Depression Inventory, n.d). To appropriately

treat this patient, BDI will give essential insight to symptoms related to this patient’s

status of depression.

Differential Diagnosis

Cross-sectional studies show a strong relationship between symptoms of depression and

insomnia due to sleep strongly influencing both development and trajectory of depression

impacting frequency severity and duration (Franzen, & Buysse, 2008). Although there is a close

relationship, a possible differential diagnosis of bipolar could be indicated. Bipolar disorder has

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shown alternating periods of elevated and depressed mood that can cause sleep disturbances

(Gold, & Sylvia, 2016). Possible indications of bipolar disorder being a differential diagnosis can

be implied to mania causing insomnia experienced. Evaluation of behaviors such as impulsivity

and labile mood can help identify trademark signs of mania.

Pharmacological Decisions

Trazodone (Desyrel) has been found to have low risks of side effects such as weight gain,

sexual drive changes, and anticholinergic effects (such as constipation, urinary retention, dry

mouth) and helpful for patients whose symptoms of depression include insomnia (Cuomo, et. al.,

2019). The unique property of trazodone is the inhibition of SERT, 5-HT2A, and 5-HT2c

receptors avoiding issues of sexual dysfunction, insomnia and anxiety that presents with SSRIs,

and SNRIs therapy. (Shin, J. J., & Saadabadi, A., 2020).

The unique property of trazodone, where it simultaneously inhibits SERT, 5-HT2A, and

5-HT2C receptors, is that it avoids the issue of sexual dysfunction, insomnia, and anxiety that

commonly presents with SSRIs and SNRIs therapy. Trazodone reduces levels of

neurotransmitters associated with arousal effects, such as serotonin, noradrenaline, dopamine,

acetylcholine, and histamine.

Mirtazapine (Remeron) is a noradrenergic and specific serotonergic antidepressant and is

commonly prescribed in the elderly population with insomnia and low weight due to the sedating

and weight gain effects (Guzman, 2019). Considering this patient’s current weight at 88kg and

64 inches, weight gain will not be beneficial for this patient. Therefore, Trazadone rather than

Mirtazapine can yield a better outcome for management of overall health. Increase in weight can

result in further issues with diabetes, blood pressure, and self-care.

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Contraindications

Trazadone has not shown any major side effects with Metformin, Januvia, Losartan, or

HCTZ. Sertraline and Trazadone can increase the risk of a rare but serious condition called

serotonin syndrome, resulting in symptoms such as confusion, hallucinations, seizure, extreme

changes in blood pressure, increased heart rage, fever, excessive sweating, shivering, or shaking,

blurred vision, muscles stiffness, tremor, incoordination, stomach cramp, nausea, vomiting, and

diarrhea (Drugs.com, 2021). Serious issues can result in coma or death causing an ethical

dilemma related to sleep and depression. Possible education of discontinuation of sertraline may

be needed if insomnia is the primary issue related to this patient. Further discussion would be

required to identify alternatives for sertraline.

References

American Psychological Association. (2005). Depression Assessment Instruments. American Psychological Association. https://www.apa.org/depression-guideline/assessment.

Beck's Depression Inventory. (n.d.). https://www.ismanet.org/doctoryourspirit/pdfs/Beck-Depression-Inventory-BDI.pdf.

Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Di Sciascio, G., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (2019). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: pharmacology and clinical practice. Rivista di psichiatria, 54(4), 137–149. https://doi.org/10.1708/3202.31796

Franzen, P. L., & Buysse, D. J. (2008, December 1). Sleep disturbances and depression: risk relationships for subsequent depression and therapeutic implications. Dialogues in ClinicalNeuroscience. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3108260/.

Gold, A. K., & Sylvia, L. G. (2016). The role of sleep in bipolar disorder. Nature and science of sleep, 8, 207–214. https://doi.org/10.2147/NSS.S85754

Guzman, F. (2019). Psychopharmacology Institute. https://psychopharmacologyinstitute.com/publication/mirtazapine-essentials-moa-indications-adverse-effects-pharmacokinetics-and-dosing-2222.

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Pilkington, K., & Wieland, L. S. (2020). Self-care for anxiety and depression: a comparison of evidence from Cochrane reviews and practice to inform decision-making and priority-setting. BMC complementary medicine and therapies, 20(1), 247. https://doi.org/10.1186/s12906-020-03038-8

Shin, J. J., & Saadabadi, A. (2020, May 28). Trazodone. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK470560/.

Trazodone and Zoloft Drug Interactions. Drugs.com. (2021). https://www.drugs.com/drug-interactions/trazodone-with-zoloft-2228-0-2057-1348.html.

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