Psychopharmacologic Approaches to Treatment of Psychopathology

only need half page. only read and respose.

Respond to the colleagues who were assigned to a different case than you. For example. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.

Below is colleague post

The case study chosen for this discussion involves that of a 70-year-old female (who will be called Ms. D. for this discussion) who presents with a complaint of “feeling sad”. Reports increased sadness and crying spells over the past year (without prior history of psychiatric illness) and poor sleep (described as “awful” and with report of “legs jumping”).  She lives alone, has hearing loss unresolved with hearing aids, and impaired mobility. 

Questions:

Three questions I would ask this patient are:

1.  What is your typical day like?  I would like to get a sense of her level of activity during the day. This will help me determine when she gets up in the morning, if she has a daily routine ( such as going to the market, attending senior center regularly, bathing, cooking, seeing friends, etc), how often she naps during the day, what her meal schedule is like ( if she is eating before bed), and what time she tries to go to sleep.
2. Is it hard to initially fall asleep, or do you wake up in the night?  This can help generate a discussion of whether it is racing or ruminative thoughts keeping the patient wake, if she is getting up to go to the bathroom (perhaps due to taking her diuretic) and that is disrupting her sleep, or if it is her complaint of “jumping legs” interrupting her sleep.
3. How long has this been going on, and is there anything that makes it better?  It is important to get a sense of the history of present complaints, and whether she is self-medicating (either with OTC medications, alcohol, etc) before determining a treatment plan.

I would definitely involve the son (with the patient’s permission) when questioning the patient due to her hearing loss.  It does not appear that she communicates using ALS and often there are nuances that can be lost in written communication, making it even more difficult to assess the patient.  I would ask the son if he has noticed a change in his mom over the past year, if he has noticed her falling asleep during conversations or at odd times during the day, if he has noticed any change in her cognition. I would also elicit information from the home health aide (again, with the patient’s permission) to get an idea of her ADLs and if they have declined over the past few months.  I would also want to determine how much of a fall risk this patient is and the aide can assist with obtaining this pertinent information.

Physical exam/diagnostics:

Geriatric Depression Scale (GDS), would be administered to assess for depression.  This is a well-validated tool in individuals with little or no cognitive impairment (Weiss, 2011).  This tool would be appropriate to administer to this patient to gauge her risk of depression.

Restless leg syndrome (RLS), estimated to affect 7-10% of the US population, can affect mood, cause daytime sleepiness, and decreased focus and concentration (all of which are presenting complaints of Ms. A.) (National Institute of Neurological Disorders and Stroke, 2019).  I would want to determine if this is the cause of some of Ms. As symptoms, however, obtaining a sleep study immediately is not always feasible.  Therefore, I would administer the RLS-DI questionnaire.  This simple screening tool is a series of 10 items designed to address the diagnostic criteria of RLS as established by the International Restless Leg Study Group and has been validated to be used by non-experts to diagnose patients with RLS (Fida, et al, 2014).  This test has been shown to have a sensitivity of 93%, a specificity of 98.9%, and correlates with results from sleep specialists 96.1% of the time (Fida, et al, 2014). 

I would also order a basic metabolic panel on this patient to assess her renal function to ensure that before initiating pharmacotherapy there is a baseline BUN/creatinine and that no renal dose modification is necessary.  Even though she is taking Ferrous Sulfate and Synthroid, I would also check an iron level (low levels of iron can exacerbate symptoms of RLS as well as cause fatigue) as well as her TSH level (hypothyroidism can result in symptoms of depression). An ECG would also be in order to be sure that there is a comparative baseline before starting any medications that could prolong QT and have adverse cardiac effects on the patient.

Although this patient is being managed medically by her primary care doctor, is important to consider all of her co-morbidities when treating her presenting symptoms.  Medical illness is a well-known contributing factor for clinical depression, and, conversely, depression is correlated with a negative prognosis in elderly patients with medical conditions (Park & Unutzer, 2011).

Differential diagnosis:

F33.1 Major depressive disorder, moderate.  The presence of daily sad mood, loss of interest in pleasurable activities, insomnia, psychomotor retardation, and diminished concentration would meet the criteria for MDD (American Psychiatric Association, 2013). It is not “recurrent” since she has had the symptoms for a year without any periods of alleviation of symptoms, and she does not endorse symptoms of psychosis. While an argument could be made for adjustment disorder (F43.21) due to the symptoms coinciding with her onset of hearing loss, (and the hearing loss is definitely exacerbating the symptoms and severity of her depression), I do not think her distress is markedly out of proportion to the stressor.  Because her low mood has been getting worse for over a year, I would initially lean towards the diagnosis of MDD.

G25.81 Restless leg syndrome.  The patient reports “jumping legs” that prevent her from sleeping.  Per the DSM-IV, RLS is characterized by the urge to move the legs during periods of rest or inactivity, partially or totally relieved by movement, and worse at night.  Symptoms have been persistent for at least three months, results in impairment and distress, unexplained by other medical condition, and not attributed to a drug or medication (American Psychiatric Association, 2013).  Assuming her blood work was negative for electrolyte imbalance, and that she screened positive on the RLS-DI tool, it is likely that Ms. A. has RLS in addition to MDD.

G47.21 Circadian rhythm sleep-wake disorder, delayed sleep phase type.  A persistent pattern of sleep disruption due to alteration in circadian rhythm leading to excessive sleepiness, insomnia, or both, causing impairment in functioning, with delayed sleep onset and awakening times (American Psychiatric Association, 2013).  While Ms. A. does have trouble falling asleep and has the urge to sleep later in the day and has impaired functioning, her difficulty sleeping and resulting daytime fatigue/lack of focus/crying spells/sadness are better explained by a diagnosis of MDD and RLS at first, however after 18 months of treatment with successful resolution of depression symptoms, the patient had recurrent insomnia and daytime fatigue, which to me indicates that this may be a viable diagnosis.

In the end, I chose to stick with MDD as this patient’s primary psychiatric diagnosis.  She has the predisposing risk factors of being female, widowed, sleep difficulties, and chronic medical ailments

Medication Regimen:

Ms. A. is currently taking the following somatic medications:

Furosemide 40mg/d, Lisinopril 40mg/d, Levothyroxizine 100mcg/d, EC Aspirin 325 mg/d,                   Allegra 180mg/d, Ferrous Sulfate 1000mg/d

The additional medications prescribed by her mental health practitioner are:

Citalopram 20mg/d, Bupriorion-XL 300mg/d, Gabapentin 600mg/d, modafinil 400mg/d, and ramelteon 16mg/bedtime.

Medication I would have chosen:

To manage the patient’s depressive symptoms, I would have started Ms. A with the Bupriorion XL 150mg/d, titrating up to 300mg/d.  Bupriorion is an NDRI that boosts norepinephrine/noradrenaline as well as dopamine (Stahl, 2014b) It is well-tolerated in the elderly and has low anticholinergic effects, so it is also well tolerated in individuals with cardiovascular disease (Weise, 2011).  I would have not started off with the SSRI citalopram because she is on a diuretic and there is a 10% risk of hyponatremia in elderly patients when SSRIs are given concurrently with diuretics (Weise, 2011). This is thought to be caused by SSRI-induced inappropriate secretion of antidiuretic hormone. Because there are so many effective antidepressants to choose from, I think the best decision is to start with one with the best side-effect profile and the least risk of adverse interactions with the patient’s other medications. My hope was that this medication would reduce her depressive symptoms and increase her daytime energy levels.  I would be sure to advise her to take in the morning so that it did not worsen her insomnia.

I would also initially treat the RSL as the primary cause of her insomnia by augmenting her Buproprion with Ropinirole, a dopamine agonist considered a first-line treatment for RLS in the elderly with the highest level of efficacy and safety (Praharaj, et al, 2018).  The neurotransmitter dopamine helps to control muscle activity and movement, and levels typically fall at night (Stahl, 2013).  Having a long-acting dopamine agonist that increases night-time levels of dopamine are effective in improving symptoms of RLS. The initial dose would be 0.25mg nightly, titrating up to a maximum dose of 4mg nightly (Praharaj, et al, 2018).  My hope would be that the improvement in RLS would allow for better sleep and further improve day time wakefulness.

If the above regimen did not lead to significant improvements, then I would have considered adding a nighttime atypical antipsychotic such as Risperdal at a low dose (1mg) to see if it improved her sleep as well as decreased her depressive symptoms. Recent open-label trials of Risperdal augmentation in elderly patients who did not obtain remission using an antidepressant showed a significant percentage of remission (Weise, 2011).  I would be careful to observe for oversedation and metabolic effects of an atypical antipsychotic due to her recent fall and obesity. If she did not tolerate this, then I would have gone with the Zolpidem 5mg nightly. 

I think that adding on multiple medications when there were two physical conditions contributing to her symptoms (the obstructive sleep apnea and hearing loss) may have been risky.  I would have liked to explore different CPAP machines that were more tolerable to the patient as well as other interpretive devices that may have allowed for some nonpharmacological treatments to see if they were effective.  Once the cochlear surgery (potentially) improved her quality of life, she may have been able to reduce or even discontinue her antidepressant.  I know she refused to wear the initial CPAP and that her sleep hygiene was not good, but addressing this by prescribing a sleep aid is not really fixing those problems and more support and education could have been offered to the patient at a much lower risk than more medications. 

This case study illustrated how complicated managing elderly patients can be; there are often so many factors contributing to a diagnosis that it can be daunting to determine which regimen to start with.