Case 1: Volume 2, Case #16: The woman who liked a late-night TV
The patient is a 70-year-old woman who exhibits symptoms of depression due to loneliness. Her son and aide assist in her care. She is hard of hearing and has other cardiological problems. She also has a family history of depression. Her ailment worsened because she was unable to sleep and consequently has s restless leg syndrome.
The three questions I will ask the patient in my office are as follows;
1. Do you feel sleepy or do you have sleep attacks during the day and describe your usual night sleep (Hours of sleep, quality of sleep, etc.)? Lack of sleep results in more health problems and worsens depression.
2. Have any members in your family been depressed? Genetic loading in depression, anxiety or schizophrenia. Get medication effectiveness of family similar to patient’s disorder.
3. Have you ever suffered from depression, anxiety or similar problems? Pt exhibited symptoms of depression-crying, sadness etc. Patient’s mother has history of depression.
Patient’s son and the home health aide are the persons assisting with his care. So, I will direct my questions to his mother as well as her home health aide about depression history, sleeping pattern, the activity of daily living and patient’s compliance with the medication regimen.
physical exams and diagnostic tests
Actigraphy is a device that measures and records movement. It is worn on the wrist and can be used as a rough measure of the sleep-wake cycle. It is useful for assessing insomnia, circadian rhythm disorders, movement disorders and an assortment of rare events (Sadock, 2015).
Polysomnography is the continuous attended, comprehensive recording of the biophysiological changes that occur during sleep. It is recorded at night and lasts between 6 and 8 hours. Brainwave activity, eye movements, submental electromyography activity, nasal-oral airway flow, respiratory effort, oxyhemoglobin saturation, heart rhythm, and leg movement during sleep are measured (Sadock, 2015).
Three differential diagnoses
1. Major Depressive Disorder (MDD)
A major depressive disorder is a depressed mood that persists for least two weeks duration or longer. Signs and symptoms of major depression include poor appetite, insomnia or hypersomnia, low energy or fatigue, low self-esteem, lack of concentration or difficulty making decisions, and feelings of hopelessness, significant weight loss or weight gain and recurring thought of death or suicide (Sadock, 2015). The predisposing factors to this illness include responses to a significant loss such as grief, a financial ruin from natural disaster, or severe medical illness or disability and other factors such as environmental (stressful life events), genetic and physiological or other psychosocial factors. All currently available antidepressants may take 3 to 4 weeks to exert significant therapeutic effects, although they may begin to show their effects earlier. Examples of antidepressant medications include SSRIs, TCAs, and MAOIs.
Sleep is regulated by basic mechanisms, and when these systems go awry, sleep disorders occur. Sleep disorders are both dangerous and difficult to treat. Obstruction Sleep Apnea (OSA) Insomnia is defined as difficulty initiating sleep. DSM-5 defines insomnia disorder as dissatisfaction with sleep quantity or quality with one or more of the following symptoms: difficulty in maintaining sleep with frequent awakenings and early morning inability to return to sleep. Primary insomnia is a condition resulting from too much arousal both at night and day time and may progress to a first major depressive episode (Stahl, 2013). Pharmacologic treatment includes Benzodiazepines, zolpidem, eszopiclone, zaleplon, and Trazodone.
3. Restless Leg Syndrome (RLS)
RLS also known as Ekbom syndrome is an uncomfortable, subjective sensation of the limbs. Usually, the legs, sometimes described as a “creepy crawly” feeling, and the irresistible urge to move the legs when at rest or while trying to fall asleep. Patients often report the sensation or any walking on the skin and crawling feelings in their legs. It worsens at night and moving the legs or walking helps to alleviate the discomfort. RLS is associated with fibromyalgia, rheumatoid arthritis, diabetes, thyroid diseases and COPD. Treatment for RLS includes levodopa, benzodiazepine, opiates, and antiepileptic (Gabapentin) drugs. Non- pharmacological treatment is massage, hot baths, hot/cold compress to affected areas, moderate exercises and alcohol avoidance at bedtime (Sadock, 2015).
Insomnia is the major diagnosis for this Patient because it is an ongoing issue.
Two pharmacologic agents for the patient’s sleep/wake therapy
The patient is on Citalopram for depression. Insomnia, fatigue and multiple painful physical complaints are side effects the medication. Citalopram increases in serotonin concentrations at serotonin receptors in parts of the brain and body other than those that cause therapeutic actions. For example, the unwanted actions of serotonin in sleep centers cause insomnia in the patient. These symptoms cause the disorder not to go into remission. Hypnotics medications will enhance remission rates for both patients with major depression and generalized anxiety disorder with insomnia. For example, Eszopiclone added to SSRI will lead to higher remission rate among the clients. Slow wave sleeping enhancing agents can also be administered to augment SSRIs/ SNRIs. These include gabapentin and Trazadone (Stahl, 2013).
Eszopiclone is a class of non-benzodiazepine hypnotic; alpha 1 isoform selective agonist of GABA-A/benzodiazepine receptors. Eszopiclone is an effective treatment for Primary insomnia, Chronic insomnia, Transient insomnia, Insomnia secondary to psychiatric or medical conditions and Residual insomnia following treatment with antidepressants. Inhibitory actions in sleep centers may provide sedative-hypnotic effects. While Eszopiclone is a hypnotic agent with a chemical structure unrelated to benzodiazepines, barbiturates, or other drugs with known hypnotic properties, it interacts with the gamma-aminobutyric acid-benzodiazepine (GABA-BZ) receptor complex. Eszopiclone binds selectively to the brain alpha subunit of the GABA A omega-1 receptor. Side effects include unpleasant taste, Sedation, Dizziness, Dose-dependent amnesia, Nervousness, Dry mouth, headache. Dosages include 2-3mg at bedtime (Drugbank.ca, 2018).
Trazodone binds at the 5-HT2 receptor; it acts as a serotonin agonist at high doses and a serotonin antagonist at low doses. Like fluoxetine, trazodone’s antidepressant activity likely results from blockage of serotonin reuptake by inhibiting serotonin reuptake pump at the presynaptic neuronal membrane. If used for long time periods, postsynaptic neuronal receptor binding sites may also be affected. The sedative effect of trazodone is likely the result of alpha-adrenergic blocking action and modest histamine blockade at the H1 receptor. It weakly blocks presynaptic alpha2-adrenergic receptors and strongly inhibits postsynaptic alpha1 receptors. Trazodone does not affect the reuptake of norepinephrine or dopamine within the CNS (Drugbank.ca, 2018).
Dosing for Depression as a monotherapy: initial 150 mg/day in divided doses; can increase every 3–4 days by 50 mg/day as needed; maximum 400 mg/day (outpatient) or 600 mg/day (inpatient), split into two daily doses. Initial 25–50 mg at bedtime; increase as tolerated, usually to 50–100 mg/day, but some patients may require up to full antidepressant dose range. Augmentation of other antidepressants in the treatment of depression: dose as recommended for insomnia (Stahl, 2013). Side effects include Nausea, vomiting, edema, blurred vision, constipation, dry mouth, Dizziness, sedation, fatigue, headache, incoordination, tremor, Hypotension, syncope, Occasional sinus bradycardia (long-term), Rare side effects are rash, and priapism.
The patient responded positively to faxes received from therapies. Now that she had her cochlear implant inserted, she can hear people thus ending some of her frustrations. She needs to get involved in different activities with people her age. In addition to her medication, the patient will benefit more from non-pharmacological interventions such as psychosocial therapies, social skills training, family-oriented therapies, case management, group therapy, and cognitive behavioral therapy (Sadock, 2015).
From psychopharmacology point of view, I will not prescribe anti-stimulant to patient. She will be on hypnotics, and I will augment with another SSRIs/SNRIs and gabapentin for neuropathic pain. As prescribed medications become effective, she will sleep well at night and the leg pain or spasm will melt away.