Pretest self-assessment question (answer at the end of the case)
Which of the following hypnotic agents is less likely to be addictive, impair psychomotor function, or cause respiratory suppression?
A. Ramelteon (Rozerem)
B. Zolpidem (Ambien)
C. Doxepin (Silenor)
D. Temazepam (Restoril)
E. A and C
F. B and D
G. None of the above
Patient evaluation on intake
70-year-old female with a chief complaint of “being sad”
Feels she had been doing well until her hearing began to diminish in both ears
– Candidate for cochlear implants in the future, but this is a long way off
– Despite the promise of improved hearing, she often has crying spells for no clear reason
Psychiatric history
The patient has been without psychiatric disorder throughout her life
Has felt increasingly sad over the last year and these feelings were not triggered by an acute stressor
Lives alone with the help of a home aide
– Her spouse died many years ago due to CAD
– Despite her aide and her son who visits often, she is having a harder time coping with both instrumental and basic activities of daily living
She admits to full MDD symptoms
– She is sad, has lost interest in things she used to enjoy, and is fatigued with poor focus and concentration
– Denies feelings of guilt, worthlessness, or any suicidal thoughts
– Appears mildly psychomotor slowed
– Additionally states that sleep is “awful”
There is no evidence of cognitive decline or memory problems
She has a supportive son who accompanies her to all appointments and helps provide her care
Social and personal history
Graduated high school, was married, and raised her children
Denied any academic issues, learning disability, or ADHD symptoms growing up
Having and maintaining friendships has been easy and successful over the years
At times, she is lonely at home
Her mobility has declined somewhat, which limits her going out
Participates in activities at a local elders’ center
No history of drug or alcohol problems
Medical history
HTN
Hypothyroidism
CAD
Anemia
Environmental allergies
Obesity
Family history
Reports AUD throughout her extended family
MDD reportedly suffered by her mother
Medication history
Never taken psychotropic medications
Psychotherapy history
Recently, has gone to a few sessions of outpatient supportive psychotherapy, but her hearing loss makes this modality almost impossible
– Hearing aids have failed to help
– May be a candidate for cochlear implants
She has a fax machine at home and states that she and her therapist often fax notes back and forth, which she finds helpful as receiving them brightens her mood
– Perhaps this is “supportive facsimile therapy”
Patient evaluation on initial visit
Gradual onset of geriatric, first-episode MDD symptoms likely as a result of hearing loss and mobility loss
This caused interpersonal disconnectedness, loneliness, and onset of MDD
Suffers from daily crying spells and seems very tired
Has good insight into her illness and wants to get better
There appears to be no suicidal or safety concerns clinically
The fatigue and possible infirmities of strength and balance may be problematic if side effects compound these symptoms
Current medications
Question
Interpersonal approaches to psychotherapy would suggest that social disconnection and loss of role function causes depression, and treating this patient by changing the way she thinks, feels, and acts in problematic relationships may help. Does this make sense for this particular patient?
Yes, this approach is evidence based in terms of providing IPT
Yes, this approach clinically fits this patient’s precipitating events prior to developing MDD
Yes, for the reasons noted. However, her inability to hear well might render IPT difficult to apply and outcomes difficult to achieve
Attending physician’s mental notes: initial evaluation
Patient has her first MDE now
It appears chronic in nature, but essentially, has been untreated
It seems more than an adjustment disorder as it is pervasive, lasting over time, and clearly disabling at this point
As this is an initial MDE and an initial foray into treatment with good family support, her prognosis is good
However, her older age of onset, loss of hearing, mobility, and marked medical comorbidity are concerning
Psychotherapy, especially IPT-based, would be clearly indicated but difficult to deliver adequately
Question
Which of the following would be your next step?
Start an SSRI such as citalopram (Celexa)
Start an SNRI such as duloxetine (Cymbalta)
Start an NDRI such as buporpion-XL (Wellbutrin-XL)
Start an NaSSA such as mirtazapine (Remeron)
Start a SPARI such as vilazodone (Viibryd)
Start a SARI such as trazodone-ER (Oleptro)
Start a multimodal serotonin receptor modulating antidepressant with geriatric depression/cognition data, such as vortioxetine (Brintellix)
Attending physician’s mental notes: initial evaluation (continued)
This case seems easy in that she is untreated up to this point; therefore, any antidepressant has a chance of working
However, there is concern regarding her obesity and lethargy; thus, avoiding medications with high weight-gain side-effect burden is warranted
Sleep is also very disrupted
Hearing loss and inability to communicate well is also problematic in providing her with good psychotherapy
– Even delineating symptoms in the medication management session is a difficult task
– Likely need to pressure and advocate for the cochlear implants acting as an antidepressant in order to advance this process
Further investigation
Is there anything else you would especially like to know about this patient?
She has marked fatigue; have medical causes been ruled out?
– She is euthyroid and her anemia is stable with a normal hematocrit
– Her cardiac function is stable and without compromise
– If she has RLS, this could account for her fatigue and should be investigated
– If she has OSA, this could account for her fatigue and should be investigated
Question
Would you increase her current SSRI medication?
Yes
Yes, only if it appears that she is partially better and her response has reached a plateau in this partial response range
No, she is a partial responder with only four weeks of treatment. Longer treatment may allow for remission
No, addition of a sleeping pill may treat insomnia and result in improved energy and concentration, thus facilitating a better overall response via polypharmacy
No, citalopram carries cardiac warnings, especially in geriatric MDD patients
Attending physician’s mental notes: second interim follow-up visit at two months
Despite being a little better, the patient is still suffering
She is crying less but there is now more of a need to improve her sleep and daytime fatigue issues
She has clinical risks for OSA (HTN, obesity, large neck size), and if this is a positive finding, CPAP treatment may be an excellent choice for her apnea and her depression residual symptoms
Her access to a sleep laboratory is limited and it may take months to have the study completed
Case outcome: second interim follow-up visit at two months
Citalopram (Celexa) is increased gradually, given her age, to 30 mg/d
– Historically, the QTc prolongation warning did not exist when this patient was prescribed this medication
– Currently, use above 20 mg/d is discouraged in the elderly
If a higher dose is needed clinically, it would make sense to obtain plasma levels and an EKG in the current era
Sleep electrophysiology is ordered to rule out OSA, RLS
She is placed on off-label tiagabine (Gabitril) as a hypnotic in order to avoid more respiratory suppressing, psychomotor impairing, sedative-hypnotic BZ or BZRA agents
– This agent has human sleep laboratory data suggesting it increases slow wave, restorative deep sleep
– Its theoretical mechanism of action is GABA reuptake inhibition, selectively at the GAT1 transporter, making it an SGRI
– She is allowed to titrate to 6 mg/d at bedtime
– This agent, interestingly, is approved to treat epilepsy but came out with a warning, well after this patient utilized this “drug” therapy that tiagabine might actually induce seizures in non-epileptic patients
The patient subsequently shows moderate improvement in her affect
Experiences slightly less RLS
Is not initiating sleep any better
She is felt to be 20%–30% better globally, but is plagued by daytime fatigue as a chief complaint
– This may actually be occurring due to the adverse effect profile of tiagabine (Gabitril)
Question
What would you do next?
Continue escalating her SSRI to a higher dose
Switch or augment with a more stimulating antidepressant
Augment with a formal stimulant
Add a formal hypnotic agent to better improve sleep
Attending physician’s mental notes: second interim follow-up visit at two months (continued)
Cannot wait months for a sleep study
Her SSRI is at a reasonable, moderate dose, and has effectively treated the target symptom of sadness and dysphoria
– Switching from this may cause a relapse
Adding a noradrenergic or dopaminergic agent may target her fatigue symptoms a little better
Adding a hypnotic may improve her sleep, and secondarily, her next day wakefulness, but need to watch for respiratory suppression and psychomotor impairment, especially if she has severe undiagnosed OSA
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