Fluent Essays

Please see attachments Instructions and case study attached Discussion Mental Health This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned. To support your work, use your course textbook readings and the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format. Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week. For this assignment, you will complete a Aquifer case study based on the course objectives and weekly content. Aquifer cases emphasize core learning objectives for an evidence-based primary care curriculum. Throughout your nurse practitioner program, you will use the Aquifer case studies to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice. The Aquifer assignments are highly interactive and a dynamic way to enhance your learning. Material from the Aquifer cases may be present in the quizzes, the midterm exam, and the final exam. Learn how to access and navigate Aquifer. This week, complete the Aquifer case titled “Family Medicine 03: 65-year-old woman with insomnia” Apply information from the Aquifer Case Study to answer the following discussion questions: Discuss the Mrs. Gomez’s history that would be pertinent to her difficulty sleeping. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know. Describe the physical exam and diagnostic tools to be used for Mrs. Gomez. Are there any additional you would have liked to be included that were not?  Please list 3 differential diagnoses for Mrs. Gomez and explain why you chose them.  What was your final diagnosis and how did you make the determination? What plan of care will Mrs. Gomez be given at this visit, include drug therapy and treatments; what is the patient education and follow-up? Case study 4.rtfd/TXT.rtf You are doing an eight-week clerkship in a family medicine practice. You review the EMR (electronic medical record) for the next patient, which identifies the patient as Mrs. Gomez, "a 65-year-old female who is here today reporting that she can't sleep." Dr. Lee, your preceptor, fills you in: "Mrs. Gomez has been a patient here for several years. Difficulty sleeping is a new issue for her. Her past medical history is significant for hypertension and diabetes. Generally, she has been doing well, although I notice that her last hemoglobin A1c has climbed to 8.7%." SLEEP HYGIENE TEACHING Dr. Lee tells you, "Poor sleeping habits can also cause insomnia. Here are some helpful tips to share with patients on sleep hygiene. For some patients, simply correcting their sleep habits by following these tips will correct their quality of sleep." TREATMENT OF INSOMNIA Treatments for Primary Insomnia in the Elderly Of the behavioral treatments, many of which may be of some assistance in the elderly, only sleep restriction/sleep compression therapy and multi-component cognitive-behavioral therapy have met evidence-based criteria for efficacy. Cognitive Behavioral Therapy for Insomnia (CBT-I) CBT-I is recommended as the first choice for most patients with insomnia. CBT-I combines behavioral treatments, resulting in improvements lasting up to two years. Recent guidelines recommend CBT-I as the first-line therapy for insomnia in adults. Examples include: Sleep restriction therapy: The patient is told to reduce his or her sleep/in-bed time to the average number of hours the patient has actually been able to sleep over the last two weeks (as opposed to the number of hours spent in bed (awake plus asleep)). As sleep efficiency increases, time allowed in bed is increased gradually by 15- to 20-minute increments approximately once every five days (if improvement is sustained) until the individual's optimal sleep time is obtained. 


 Relaxation therapy: Structured exercises designed to reduce somatic tension (eg, abdominal breathing, progressive muscle relaxation; autogenic training) and cognitive arousal (eg, guided imagery training; meditation) that may perpetuate sleep problems. 


 Agents evaluated in older patients: Class Agents Improves Strength of evidence Considerations Benzodiazepine Receptor Agonists zolpidem (Ambien) eszopiclone (Lunesta) SOL SOL, TST, WASO, sleep efficiency low Risks for falls and fractures, mood alteration Short term use only Use lower doses Tricyclic Antidepressants doxepin SOL, TST, WASO low to moderate Anticholinergic effects, sedation, and orthostatic hypotension Orexin Receptor Antagonist suvorexant (Belsomra) SOL, WASO moderate Decreased alertness and increased fatigue morning after use Melatonin Receptor Agonist ramelteon SOL low Somnolence, mood alteration and dizziness Abbr: SOL - sleep onset latency, TST - total sleep time, WASO - wake after sleep onset Benzodiazepines and orexin receptor antagonists can be effective but have more complications and the additional risk of addiction. Antihistamines, antidepressants including trazodone (in the absence of depression), anticonvulsants, and antipsychotics are associated with more risks than benefits in older adults. The evidence base for exercise as a treatment for insomnia is less extensive. Despite this, there are many other reasons to encourage regular physical activity in the elderly, assuming there are no other contraindications to such activity. There is limited research, particularly in the elderly, on complementary therapies including melatonin, L-Tryptophan, valerian, chamomile, kava, and wuling. What evidence that does exist suggests that any potential benefit is equaled or exceeded by potential adverse effects, particularly in the case of valerian. They are not recommended. Family Medicine 03: 65-year-old female with insomnia Author: William Hay, MD; Associate Editor: Martha P. Seagrave RN, PA-C; Case Editor: William Hay, MD INTRODUCTION HISTORY SLEEP HYGIENE TEACHING TREATMENT OF INSOMNIA TEACHING Question Which treatments are recommended in the elderly? Select all that apply. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Antidepressants B. Antihistamines C. Benzodiazepines D. Cognitive behavioral therapy E. Zolpidem SUBMIT Answer Comment The correct answer is D. TEACHING POINT Treatments for Primary Insomnia in the Elderly Of the behavioral treatments, many of which may be of some assistance in the elderly, only sleep restriction/sleep compression therapy and multi-component cognitive-behavioral therapy have met evidence-based criteria for efficacy. Cognitive Behavioral Therapy for Insomnia (CBT-I) CBT-I is recommended as the first choice for most patients with insomnia. CBT-I combines behavioral treatments, resulting in improvements lasting up to two years. Recent guidelines recommend CBT-I as the first-line therapy for insomnia in adults. Examples include: Sleep restriction therapy: The patient is told to reduce his or her sleep/in-bed time to the average number of hours the patient has actually been able to sleep over the last two weeks (as opposed to the number of hours spent in bed (awake plus asleep)). As sleep efficiency increases, time allowed in bed is increased gradually by 15- to 20-minute increments approximately once every five days (if improvement is sustained) until the individual's optimal sleep time is obtained. 


 Relaxation therapy: Structured exercises designed to reduce somatic tension (eg, abdominal breathing, progressive muscle relaxation; autogenic training) and cognitive arousal (eg, guided imagery training; meditation) that may perpetuate sleep problems. 


 Agents evaluated in older patients: Class Agents Improves Strength of evidence Considerations Benzodiazepine Receptor Agonists zolpidem (Ambien) eszopiclone (Lunesta) SOL SOL, TST, WASO, sleep efficiency low Risks for falls and fractures, mood alteration Short term use only Use lower doses Tricyclic Antidepressants doxepin SOL, TST, WASO low to moderate Anticholinergic effects, sedation, and orthostatic hypotension Orexin Receptor Antagonist suvorexant (Belsomra) SOL, WASO moderate Decreased alertness and increased fatigue morning after use Melatonin Receptor Agonist ramelteon SOL low Somnolence, mood alteration and dizziness Abbr: SOL - sleep onset latency, TST - total sleep time, WASO - wake after sleep onset Benzodiazepines and orexin receptor antagonists can be effective but have more complications and the additional risk of addiction. Antihistamines, antidepressants including trazodone (in the absence of depression), anticonvulsants, and antipsychotics are associated with more risks than benefits in older adults. The evidence base for exercise as a treatment for insomnia is less extensive. Despite this, there are many other reasons to encourage regular physical activity in the elderly, assuming there are no other contraindications to such activity. There is limited research, particularly in the elderly, on complementary therapies including melatonin, L-Tryptophan, valerian, chamomile, kava, and wuling. What evidence that does exist suggests that any potential benefit is equaled or exceeded by potential adverse effects, particularly in the case of valerian. They are not recommended. icon-circle-expand-1.svg ¬DEEP DIVE References Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2):255-62. Flaxer JM, Heyer A, Francois D. Evidenced-Based Review and Evaluation of Clinical Significance: Nonpharmacological and Pharmacological Treatment of Insomnia in the Elderly. Am J Geriatr Psychiatry. 2021;29(6):585-603. Matheson E, Hainer BL. Insomnia: Pharmacologic Therapy. Am Fam Physician. 2017;96(1):29-35. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;165(2):125-33. REASON FOR VISIT After discussing these potential causes of insomnia with Dr. Lee, you feel prepared to talk with Mrs. Gomez. You knock on the exam room door and enter to find Mrs. Gomez, who is accompanied by her daughter, Silvia. You introduce yourself and ask if you may ask her a few questions, to which she agrees. "What brings you to the clinic today?" "Tell me more about this." On further questioning, Mrs. Gomez reports no discomfort such as pain or breathing problems disturbing her sleep. She reports no snoring, apneic spells (a period of time during which breathing stops or is markedly reduced), or physical restlessness during sleep. Her daughter agrees that she has not seen these problems. She rarely consumes alcohol or caffeine. When you ask if anything like noise or an uncomfortable sleeping environment might be bothering her, she replies that this is not a problem - but her daughter interjects: "Yes, in fact Mom's waking up the rest of us, walking around and turning on the TV. My husband and I both work. So we all need our rest. Mom came to live with us last year after Dad passed away. We're her only family around here and we thought we should help her." RELATED HISTORY You tell Mrs. Gomez, "I'm sorry to hear about your husband." "Do you find that you feel sad most of the time?" Silvia states, "But Mom, you spend most of your time just moping around the house." Turning to you she elaborates, "She seems to be in slow motion most of the time. She doesn't even go to church anymore. She used to go three to four times a week. She used to read all the time, and she doesn't do that anymore either." Mrs. Gomez explains, "I haven't been reading as much as I used to because I can't seem to focus and I end up reading the same page over and over." She goes on to say, "And I don't seem to have any energy to do anything. I'm not even able to help out around the house. I feel bad about that; I should be helping out more. I seem to spend a lot of time just watching TV and eating junk food." PAST MEDICAL HISTORY AND MEDICATIONS HISTORY You ask, "Have you tried anything to help you sleep?" "I'm not familiar with that product, but I'll mention it to Dr. Lee. I'm glad you brought it up. It's important that your doctors know about everything you are taking, whether it's prescription medication or not. I'm sorry nothing seems to be helping you sleep. We'll get to the bottom of this together." You turn your attention to taking Mrs. Gomez's past medical history. You learn: Problem list: Hypercholesterolemia Type 2 diabetes Hypertension 


 Surgical history: Cholecystectomy Hysterectomy (due to fibroids) 


 Medications: For diabetes: Glyburide (10 mg daily) Metformin (1,000 mg bid) 


 For blood pressure: Methyldopa (250 mg bid) Lisinopril (10 mg daily) 


 For cholesterol: Atorvastatin (80 mg daily) 


 For CHD prophylaxis: Aspirin (81 mg daily) 


 For osteoporosis prevention: Calcium citrate with vitamin D (600mg/400 IU bid) 


 Diphenhydramine is her only over-the-counter medication, and she is taking no traditional or herbal medications beyond the zapote tea. Social History She does not smoke, and drinks only small amounts of alcohol on holidays. DIFFERENTIAL DIAGNOSIS CLINICAL REASONING Given what you have heard from Mrs. Gomez and her daughter, especially Her inability to focus Her lack of energy The sense that she is in slow motion She has stopped doing activities she previously enjoyed 


 You are concerned that her insomnia may be due to depression. Depression may stem from environmental stressors such as her husband's death and her loss of independence along with a primary neurochemical imbalance. Her depression also could be caused by another medical condition. REVIEW OF SYSTEMS HISTORY Keeping in mind the disorders associated with depression, you elicit a review of systems from Mrs. Gomez to help discover what these indicate regarding her underlying illness. Constitutional: Mrs. Gomez has gained about 10 lbs in the last six months. She reports no fevers or dizziness. This makes you less concerned about cancer or other systemic illness. Respiratory: No shortness of breath, making cardio-respiratory disease less likely. Cardiac: No chest pains, palpitations or edema, decreasing the likelihood of cardiovascular disease. Gastrointestinal: No nausea, changes in bowel habits, hematochezia or melena. This makes you less concerned about gastrointestinal cancer or occult blood loss leading to anemia. Endocrinologic: No polydipsia or polyuria, decreasing the likelihood of poorly controlled diabetes. Neurologic: No acute neurologic changes or tremors. Her daughter confirms that her mother has been alert, oriented, and has had no episodes of confusion. So you are now less concerned about cerebral infarction, intracranial tumors, multiple sclerosis, and Parkinson disease. Urologic: Normally urinates one to two times at night. Once you have completed your review of systems, you excuse yourself from the room for a moment while Mrs. Gomez changes into a gown. PHYSICAL EXAM PHYSICAL EXAM You perform a physical exam on Mrs. Gomez. When you return to the exam room, after washing your hands, you perform a physical exam on Mrs. Gomez. Vital signs: Pulse is 60 beats/minute and regular Respiratory rate is 16 breaths/minute Blood pressure is 128/78 mm Hg Weight is 84 kg (186 lbs (up 10 lbs since last year)) Height is 163 cm (64 in) 


 Head, eyes, ears, nose and throat (HEENT): No thyromegaly, adenopathy, or masses. Cardiac: Regular rate and rhythm, no murmur or gallops. No edema. Respiratory: Clear to auscultation. Abdominal: Soft, nontender, without organomegaly or masses. Neurologic: Cranial nerves 3-12 intact. Normal strength and light touch sensation in extremities. No tremors. Normal gait. ASSESSING MENTAL HEALTH STATUS PHYSICAL EXAM You are afraid your next question may upset Mrs. Gomez, but you know it is important to ask: "Mrs. Gomez, I have one more question: When people are down, sometimes they wish they would fall asleep and never wake up. "Have you had any thoughts of dying or causing harm to yourself?" "Okay, thank you for your openness with me," you tell Mrs. Gomez. "I would like to bring in Dr. Lee so she can also perform a physical exam before you get dressed. We'll be back in just a minute. Do you have any questions for me before I go?" Mrs. Gomez indicates she doesn't have any concerns, so you exit the room. DIAGNOSTIC CRITERIA PHYSICAL EXAM You present your concern that Mrs. Gomez is depressed. You locate Dr. Lee and present the case to her, expressing your concern that Mrs. Gomez is depressed. She suggests discussing the evidence you found that Mrs. Gomez may have depression. You tell Dr. Lee, "Mrs. Gomez has a depressed mood and seven of the nine criteria." TEACHING POINT Major Depression Diagnostic Criteria For a diagnosis of major depression, the patient must have at least five of the following nine criteria for a minimum of two weeks. A least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure. 


 Depressed Mood (The eight remaining criteria can be remembered using the mnemonic SIG E CAPS): Sleep: Insomnia or hypersomnia nearly every day. Interest (loss of): Anhedonia (loss of interest or enjoyment) in usual activities. Guilt: Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). Energy (decreased): Fatigue or loss of energy nearly every day. Concentration (decreased, or crying): Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). Appetite (increased or decreased): or significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month). Psychomotor retardation: Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). Suicidal ideation: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. DISCUSSING DIAGNOSIS TEACHING "You seem to have established that Mrs. Gomez meets the criteria for a major clinical depression," says Dr. Lee, and goes on to explain: TEACHING POINT Major Depressive Disorder versus Bereavement The presence of certain symptoms that are not characteristic of a "normal" grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode. The table below adapted from the DSM V discusses some potential differences: Major Depressive Episode Bereavement (Grief) Persistent depressed mood and inability to anticipate happiness or pleasure Feelings of emptiness and loss Depression persistent, not tied to specific thoughts or preoccupations Depressed feelings often decrease in intensity over days to weeks and occur in waves, associated with thoughts of the deceased Pervasive unhappiness and misery Grief may be accompanied by positive emotions and humor Self-critical or pessimistic ruminations Preoccupation with thoughts and memories of the deceased Feelings of worthlessness and self-loathing Self-esteem is generally preserved. May be self-deprecating—feeling they should have done more or told the deceased how much he or she was loved Suicidal ideation because of feeling worthless, undeserving of life, or unable to cope with the pain of depression Individual thinks about death and dying, generally focused on the deceased and possibly about joining the deceased TEACHING POINT Risk factors for Late-life depression Risk factors for late-life depression include: Female sex Social isolation Widowed, divorced, or separated marital status Lower socioeconomic status Comorbid general medical conditions, e.g. stroke, heart disease and cancer Uncontrolled pain Insomnia Functional impairment Cognitive impairment 


 TEACHING POINT Depression in the Elderly Depression is a very serious disease in the elderly: Depression increases the risk of disabilities in mobility and the activities of daily living by about 70% over the course of six years. Alcohol and drug abuse are very common comorbidities complicating depression. Completed suicide is more common in older depressed patients. RISK ASSESSMENT CARE DISCUSSION You express to Dr. Lee your concern that by asking about suicide you may have made the situation worse. Dr. Lee reassures you: "Many people worry that bringing up the subject of suicide will cause the patient to commit suicide. On the contrary, talking about it allows the opportunity to intervene and prevent a completed suicide." TEACHING POINT Suicide Assessment Five-step Evaluation and Triage (SAFE-T) Suicide Assessment Five-step Evaluation and Triage (SAFE-T) 1. RISK FACTORS a. Suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior b. Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity) Co-morbidity and recent onset of illness increase risk c. Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, and command hallucinations d. Family history: of suicide, attempts, or psychiatric disorders requiring hospitalization e. Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation f. Change in treatment: discharge from psychiatric hospital, provider or treatment change g. Access to firearms 2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk a. Internal: ability to cope with stress, religious beliefs, and frustration tolerance b. External: responsibility to children or beloved pets, positive therapeutic relationships, and social supports 3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, and intent a. Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever b. Plan: timing, location, lethality, availability, and preparatory acts c. Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) versus non-suicidal self injurious actions d. Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal versus self-injurious. e. Explore ambivalence: reasons to die versus reasons to live ›For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition ›Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above 4. RISK LEVEL/INTERVENTION a. Assessment of risk level is based on clinical judgment, after completing steps 1–3 b. Reassess as patient or environmental circumstances change 5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with significant others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plans should include roles for parent/guardian. SCREENING TOOLS Mrs. Gomez fills out a Mini-Cog exam. Entering the room with you, Dr. Lee greets Mrs. Gomez and her daughter, and thanks them for allowing you to interview them. She tells Mrs. Gomez, "I understand that you've been having trouble sleeping - not unusual given your recent stresses. These can also lead to feelings of depression. I'd like to look into this by going over a short questionnaire with you." Dr. Lee goes over the questions on the Geriatric Depression Scale - Short Form (GDS-SF) with Mrs. Gomez. Her score equals 9. This confirms depression, as a score of > 5 is consistent with the diagnosis of depression. Dr. Lee then performs a Mini-Cog exam to screen for dementia, explaining to Mrs. Gomez that in cases like this, checking out the patient's memory and concentration can help to rule out other disorders and can assist in planning treatment. She scores in the normal range. TEACHING POINT Screening for Depression The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression, but especially patients with chronic diseases like diabetes, as they are at high risk for depression. The PHQ-2 is a simple screen that is 97% sensitive and 59% specific as a depression screen: "Over the past two weeks, have you often been bothered by either of the following problems?" Little interest or pleasure in doing things. Feeling down, depressed, or hopeless. 


 If positive, it should be followed up by a diagnostic instrument such as: PHQ-9 Geriatric Depression Scale - Short Form (GDS-SF) (.pdf) 


 TEACHING POINT Screening for Dementia in Geriatric Patients with Depression While screening for dementia in asymptomatic individuals is not recommended (I statement), screening is important in geriatric patients with depression because the Geriatric Depression Scale is less sensitive in patients experiencing dementia. Two dementia screening tools are: The Mini-Cog exam The Mini-Mental State Exam (MMSE) 


 The Mini-Cog exam is faster and more sensitive and specific than the MMSE. Sensitivity Specificity Mini-Cog 99% 93% MMSE 91% 92% TEACHING POINT Patient Health Questionnaire, Two-Item Version (PHQ-2) The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. Many family physicians and students are familiar with the nine-item depression survey from the Patient Health Questionnaire (PHQ-9), which has been demonstrated to be useful in diagnosis and tracking the severity of symptoms among patients with major depression. The length of the questionnaire has been a barrier to its use as a screening tool in primary care, where physicians are under considerable time pressure and face competing demands. More recently, a shortened two-item version (PHQ-2) has been developed and validated in primary care. The PHQ-2 asks patients, "Over the last two weeks, how often have you been bothered by any of the following problems?" The two symptoms are "little interest or pleasure in doing things" and "feeling down, depressed, or hopeless." For each question the patient can answer: Not at all (0 points) Several days (1 point) More than half the days (2 points) Nearly every day (3 points) 


 The score from the two symptom questions are then added together into a final score. MEDICATIONS AND MECHANISMS OF ACTION TEACHING "Now that we know Mrs. Gomez is depressed," states Dr. Lee, "Let's talk about the different groups of antidepressant medications and how they work." TEACHING POINT Antidepressant Medications Most antidepressants work by improving the levels of the neurotransmitters norepinephrine (NE), serotonin (5HT), and dopamine (DA). There are four major classes of antidepressants: Others Class Mechanism Examples Selective serotonin reuptake inhibitors (SSRIs) Selectively block reuptake of serotonin, potentiating serotonin's effect on the postsynaptic neuron Citalopram (Celexa) Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Escitalopram (Lexapro) Tricyclic antidepressants (TCAs) Block reuptake of norepinephrine and serotonin, potentiating their effects on the postsynaptic neuron Nortriptyline (Pamelor) Amitriptyline Clomipramine (Anafranil) Doxepin (Sinequan) Monoamine oxidase (MAO) inhibitors Block presynaptic catabolism of norepinephrine and serotonin (rarely used today) Phenelzine (Nardil) Tranylcypromine (Parnate) Serotonin and norepinephrine reuptake inhibitors Block reuptake of norepinephrine and serotonin, increasing their concentration/availability Venlafaxine (Effexor) and Duloxetine (Cymbalta) Others Norepinephrine and dopamine reuptake inhibitors Bupropion (Wellbutrin) Serotonin antagonist and reuptake inhibitors Nefazodone (Serzone) and Trazodone (Desyrel) Norepinephrine and serotonin antagonist, antihistaminic effects Mirtazapine (Remeron) Serotonin partial agonist and reuptake inhibitor Vilazodone (Viibryd) TREATMENT OF CHOICE 1 CLINICAL REASONING Question Which of the following would be considered treatment(s) of choice in this clinical scenario? Select all that apply. The best options are indicated below. Your selections are indicated by the shaded boxes. A. Amitriptyline - a tricyclic antidepressant B. Cognitive-behavioral therapy C. Electroconvulsive therapy (ECT) D. Exercise E. Sertraline - a selective serotonergic reuptake inhibitor (SSRI) SUBMIT Answer Comment The correct answers are B, D, E. Dr. Lee concludes, "In the elderly, the chance of spontaneous remission of depression is much lower than in younger patients, so it's best we start some form of therapy. I agree that an SSRI and/or psychotherapy would be a good choice for Mrs. Gomez. Also, the death of her husband and moving into a new environment proved to be stressful for her. Cognitive therapy can help her cope with these life changes." TEACHING POINT Management of Depression When treating patients with major depression disorder, a biopsychosocial approach should be considered. "Bio" refers to pharmacotherapy; "psycho" refers to psychotherapy; and "social" refers to the identification of life stressors. While either medication or counseling can be effective when used alone, using the two treatment modalities concurrently offers the patient the most beneficial and comprehensive therapy, and is associated with the highest rates of remission. Medication: In a first episode of depression, it's usually recommended that the patient take the medication for nine to 12 months, as stopping any sooner runs a high risk for recurrence. Recurrent episodes of depression are treated for two to three years. With multiple recurrences and - in the elderly, who experience increased rates of recurrence - continuous therapy should be considered. SSRIs, such as sertraline, and SNRIs are …