Assignment: Understanding Insomnia 

Assignment: Understanding Insomnia 

Assignment: Understanding Insomnia

In the case study, a 75-year-old woman comes with complaints of insomnia. She reports having worsening depression and insomnia since her husband died ten months ago. The purpose of this paper is to describe questions for the patient, the differential diagnosis, and the drug therapy plan.

Questions I Might Ask the Patient

1. Which other symptoms do you experience apart from the depressed mood and sleep disturbance? This will establish if the patient has other symptoms that fit the diagnosis of depression.
2. Do you usually think you were better off dead or have thoughts about death? This will assess for suicidal ideation and thoughts that occur in depression (Park & Zarate, 2019).
3. How have the symptoms interfered with your daily activities and social interactions? To establish the impact of the symptoms on the patient’s functioning.
   

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I would need to speak to the patient’s caregiver to inquire about the challenges the patient experiences at home and how her behavior has changed in the past weeks. I would ask:

1. How has the patient’s depression interfered with how she interacts with people? To assess the impact of depression on social functioning.
2. What ADLs does the patient encounter challenges in performing independently? To assess the patient’s independence in ADLs (Park & Zarate, 2019).
3. Does the patient usually put herself in circumstances that endanger her? To assess for self-harm behaviors.

Appropriate Physical Exams and Diagnostic Tests

A neurological examination would be important for this patient to rule out any neurological disorders contributing t the symptoms. Depression screening using PHQ-9 or Beck Depression Inventory (BDI) would be essential to assess the severity of the patient’s depression and guide in making a diagnosis of depression. Important lab tests will include

CBC count, Thyroid-stimulating hormone, BUN, Creatinine, and Vitamin B-12 (Park & Zarate, 2019). The results will help to rule out organic causes of depression.

Differential Diagnosis

Major depressive disorder (MDD) is the differential diagnosis for this patient owing to positive symptoms of a worsening depressed mood, insomnia, and a history of MDD. A depressed mood is one of the primary symptoms of MDD, and sleeping disturbance is common. The patient’s worsening depression, even with Sertraline treatment, indicates treatment-resistant depression (TRD) (Demyttenaere & Van Duppen, 2019).

Pharmacologic Agents

The proposed drug therapy for the patient’s TRD are:

1. Aripiprazole (Abilify) 5 mg/day PO. This is a Serotonin-dopamine activity modulator (SDAM) recommended as an adjunct treatment for MDD and indicated for TRD (McDonald & Stevermer, 2019).
2. Buspirone (BuSpar) 7.5 mg twice daily PO. Buspirone has antidepressant effects that increase when combined with SSRIs or TCAs in patients with TRD (Davies et al., 2019).

Aripiprazole will be preferred over Buspirone because it is more effective and does not require an SSRI or TCA augmentation. McDonald & Stevermer (2019) explain that short-term use of Aripiprazole significantly alleviates depression in patients who resist SSRI or SNRI treatment. It is contraindicated in patients hypersensitive to the drug and for dementia-related psychosis since it increases mortality risk.

Checkpoints: The patient will be followed-up after four weeks to evaluate the improvement of symptoms, and the Aripiprazole dose will be increased by 5 mg/day after four weeks to a maximum of 15mg/day.

References

Davies, P., Ijaz, S., Williams, C. J., Kessler, D., Lewis, G., & Wiles, N. (2019). Pharmacological interventions for treatment-resistant depression in adults. The Cochrane database of systematic reviews, 12(12), CD010557. https://doi.org/10.1002/14651858.CD010557.pub2

Demyttenaere, K., & Van Duppen, Z. (2019). The Impact of (the Concept of) Treatment-Resistant Depression: An Opinion Review. The international journal of neuropsychopharmacology, 22(2), 85–92. https://doi.org/10.1093/ijnp/pyy052

McDonald, C., & Stevermer, J. J. (2019). How effective is Aripiprazole in treatment-resistant major depression?. Evidence-Based Practice, 22(7), 27-28. https://doi.org/10.1097/EBP.0000000000000313

Park, L. T., & Zarate, C. A., Jr (2019). Depression in the Primary Care Setting. The New England journal of medicine, 380(6), 559–568. https://doi.org/10.1056/NEJMcp1712493