The Depression And Prolonged Grief Disorder Discussion

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: The Depression And Prolonged Grief Disorder Discussion

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Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily
Current weight: 88 kg

Current height: 64 inches

Temp: 98.6 degrees F

BP: 132/86

By Day 3 of Week 7
Post a response to each of the following:

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other The Depression And Prolonged Grief Disorder Discussion.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.

Patient evaluation requires an understanding of how they feel. While patients may present symptoms similar to other diseases. This discussion post focuses on assessing and the correct diagnosis of a patient suffering from depression who may also have a Prolonged Grief Disorder (PGD) diagnosis.

The Questions and Their Rationale

Question

For how long have you been receiving primary care and being on the Sertraline 100mg daily dosage? Do you still experience sleep problems alongside any signs of depression?

Rationale

To have an understanding of whether the medication had helped improve the patient’s depressive symptoms on drug administration to the current date. Prolonged usage of approximately one month with no decline in the symptoms and increased adversities on the side effects would lead to the change in the antidepressants for a fastened recovery process The Depression And Prolonged Grief Disorder Discussion.

Question

Do you experience any difficulties in sleeping during the night or have to use anything to help improve your sleep? Were there any problems with your sleeping habits before your husband’s death?

Rationale

The question will help determine any causes of loss of sleep and the patient’s history associated with current insomnia, or the remedies required to eradicate using any medication to help with improving the patient’s sleep.

Question

Do you have any close members like friends and family who visit and listen to you as you continue with your medication?

Rationale

Asking about the patient’s support system will help determine the increased chances of prolonged depression due to the likelihood of staying in isolation.

Source: Meawad Elsayed (2019)

Further Patient Assessment and Feedback

Based on the questions identified in this discussion, I would then seek to have maximum inclusion with the patient’s support system to ensure maximum safety by frequently asking about their progress and educating them on how to seek help if any need it. What’s more, the specific questions asked would be

• Does she adhere to the correct medication and dosage?
• Have the depressive symptoms declined? For example, the loss of appetite, increased anxiety, lack of sleep, and increased disinterest in activities they used to love participating in.

Asking the provided questions and talking with the close members will help determine any areas that require immediate support to help in ensuring improved patient life quality and safety The Depression And Prolonged Grief Disorder Discussion

Source: Moeini et al. (2018)

Physical Exams and the Diagnostics Tests

Due to the patient’s old age, a Geriatric Depression Scale (GDS) is recommended for depression screening (Durmaz, 2017) Similarly, Łukaszyk et al. (2018) suggest that completing a Mini-Mental State Exam (MMSE) would help determine the patient’s cognitive functioning and ensure that her coordination and memory are excellent. A lab diagnosis is also essential in determining any potential changes that may implicate the patient’s mood. For instance, a depressive mood would be caused by an inadequacy of vitamin B12 (Łukaszyk et al., 2018)

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Potential Differential Diagnosis

The differential diagnosis, in this case, would be prolonged grief disorder (PGD) due to the loss of a loved one. Similarly, the American Psychiatry Association (2013) in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) tool also emphasizes that PGD symptoms may be similar to depression due to the individual’s presenting anxiety, lack of sleep, dissatisfaction, and low life quality, hence the mist suitable differential diagnosis The Depression And Prolonged Grief Disorder Discussion.

Recommended Antidepressant Therapies

The recommended first-line medication I would administer to the patient is a 50mg daily dosage of Trazodone drugs to counter sleeping difficulties at night and improve the effectiveness of the already administered medication for depression (Eudaley et al., 2022). On the other hand, using Bupropion XL 150mg daily dose would help lower depressive symptoms instead of the current medication or Bupropion to treat anxiety and depressive symptoms and lower anticholinergic effects and sedation which occur from using Sertraline (Eudaley et al., 2022).

Contraindications and Potential Adjustments

According to Schwasinger-Schmidt and  Macaluso (2018), the administration of Trazodone in patients is contraindicated to patients under Monoamine oxidase inhibitors (MAOIs) treatment or those confirmed to take them in the recent two weeks due to inhibiting their actions. The administration of Trazodone should also be during the night due to fast absorption on ingestion, besides its likelihood to cause sedation and cardiac arrhythmias in patients with heart-related diseases (Schwasinger-Schmidt &  Macaluso, 2018)The Depression And Prolonged Grief Disorder Discussion. Lastly patients susceptible to seizures and suffering from posttraumatic epilepsy should not consume bupropion. In this case, there is no potential adjustments on the treatment administered to the patient.

Outcome Follow-up Check Points and Potential Changes

A recommended follow-up patient schedule after four weeks would be to evaluate the patient’s state based on the recommended prescription to determine drug effectiveness and any adversities to help come up with a plan to counter any current problems. Understanding the changes in the previously reported symptoms such as insomnia, anxiety, and mood changes would help determine whether there is a need for adjustments in the current conventional care plan. If the depressive symptoms are seen to have reduced, then it would mean that the drugs are working, hence no adjustments as opposed to no changes which would mean an increased dosage of Trazodone or Bupropion and a subsequent follow-up for patient monitoring in the next four weeks (week eight)The Depression And Prolonged Grief Disorder Discussion.

Conclusively, the discussion post suggests that while serotonin drugs may have been recommended for use, there are other medications that may be used as first-line medicines in treating depression. Hence, understanding the side effects and how effective medicines work is crucial in ensuring maximum patient safety.

References

American Psychiatry Association. (2013). DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FIFTH EDITION DSM-5TM (5th ed.). APA.

Durmaz, B. (2017). Validity and reliability of geriatric depression scale – 15 (Short form) in Turkish older adults. Northern Clinics of Istanbul. https://doi.org/10.14744/nci.2017.85047

Eudaley, S. T., Brooks, S. P., & Hamilton, L. A. (2022). Case report: Possible serotonin syndrome in a patient taking Kratom and multiple Serotonergic agents. Journal of Pharmacy Practice, 089719002211160. https://doi.org/10.1177/08971900221116009

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Łukaszyk, E., Bień-Barkowska, K., & Bień, B. (2018). Cognitive functioning of geriatric patients: Is Hypovitaminosis D the next marker of cognitive dysfunction and dementia? Nutrients, 10(8), 1104. https://doi.org/10.3390/nu10081104

Meawad Elsayed, E. B. (2019). Relationship between social support, loneliness, and depression among elderly people. International Journal of Nursing Didactics, 09(01), 39-47. https://doi.org/10.15520/ijnd.v9i01.2412 The Depression And Prolonged Grief Disorder Discussion