Case: An elderly widow who just lost her spouse.

Full Answer Section

People to Speak To:

1. Close friends or family: (Ask about observed changes in mood, behavior, social engagement, and daily functioning. Inquire about support networks and potential concerns they might have.)
2. Previous healthcare providers: (Request medical records and previous treatment plans for depression or other relevant conditions.)

Physical Exams and Diagnostic Tests:

1. Physical examination: (Assess vital signs, thyroid function, and any potential medical contributors to insomnia or depression.)
2. Thyroid function tests: (Hypothyroidism can mimic symptoms of depression and insomnia.)
3. Sleep study: (May be considered in severe cases to rule out sleep apnea or other sleep disorders.)

Differential Diagnosis:

1. Major depressive disorder: Most likely diagnosis given the presenting symptoms and recent bereavement.
2. Adjustment disorder with depressed mood: May be considered if symptoms are primarily related to the loss and resolve within 6 months.
3. Generalized anxiety disorder: Less likely but possible if anxiety is the predominant symptom interfering with sleep.
4. Sleep apnea: Uncommon at this age but should be considered if physical exam or history suggests risk factors.

Pharmacologic Agents:

1. Mirtazapine 15mg nightly: Has sedative and appetite-stimulating properties, potentially improving sleep and addressing weight loss.
2. Escitalopram 10mg daily: Selective serotonin reuptake inhibitor (SSRI) with minimal side effects and good tolerability in older adults.

Rationale for Selection: Mirtazapine's sedative effect and ability to increase appetite might be beneficial for this patient's specific needs, though escitalopram's tolerability and safety in older adults are also important considerations.

Contraindications and Dosing Alterations:

• Mirtazapine: Hypotension risk – Monitor blood pressure closely. Start with lower dose and titrate slowly.
• Escitalopram: QTc prolongation risk in older adults – Monitor EKG and electrolytes. Consider lower initial dose.

Follow-up and Therapeutic Changes:

• Week 4: Assess sleep quality, mood, and overall well-being. Consider dose adjustment if needed.
• Week 8: Evaluate response to treatment. Monitor for potential side effects.
• Week 12: Continue monitoring progress, adjust medication or therapy as needed. Address any unresolved grief or persistent symptoms.

Additional Points:

• Consider referral to psychotherapy for grief counseling and cognitive-behavioral therapy for insomnia.
• Encourage healthy sleep hygiene practices and exercise.
• Provide support resources for bereavement and mental health services.

Sample Answer

Patient Questions:

1. Describe your typical sleep schedule before and after your husband's passing. (Rationale: Assess baseline sleep patterns and identify any changes in duration, quality, or sleep habits associated with the bereavement.)
2. What activities or thoughts typically keep you awake at night? (Rationale: Identify potential contributing factors to insomnia, such as anxiety, rumination, or grief-related thoughts.)
3. Have you noticed any changes in your appetite, energy levels, or motivation since your husband's death? (Rationale: Screen for broader depressive symptoms beyond insomnia and assess overall emotional well-being.)