An 82-year-old woman comes to the physician due to sadness, anxiety, tearfulness, insomnia, and weight loss. She lies awake at night worrying and no longer has any interest in her usual hobby of playing bridge or visiting her grandchildren. She has lost 6.8 kg (15 lb) over the past 2 months. Physical examination and laboratory results, including thyroid function tests, are normal.
Which of the following medications would be best to treat this patient's symptoms?

Question

An 82-year-old woman comes to the physician due to sadness, anxiety, tearfulness, insomnia, and weight loss.  She lies awake at night worrying and no longer has any interest in her usual hobby of playing bridge or visiting her grandchildren.  She has lost 6.8 kg (15 lb) over the past 2 months.  Physical examination and laboratory results, including thyroid function tests, are normal.
Which of the following medications would be best to treat this patient's symptoms?

Quizplus · Accepted Answer

Because all available antidepressants have comparable efficacy, drug selection is based on other factors, including specific depressive symptoms and side effect profile. Mirtazapine is an atypical antidepressant that, due to its sedating properties and stimulation of appetite and weight gain, has been particularly effective in treating geriatric depression associated with weight loss and poor sleep. Mirtazapine is classified as a noradrenergic and specific serotonergic antidepressant because it antagonizes presynaptic alpha-2 adrenergic receptors and postsynaptic serotonin 5-HT2 and serotonin 5-HT3 receptors. Blockade of histamine H1 receptors may underlie its sedative and appetite-stimulating properties. (Choices A and D) Amitriptyline and nortriptyline are tricyclic antidepressants that are no longer considered first-line agents for geriatric depression due to their side effect profile. Risks include orthostatic hypotension, anticholinergic side effects, and potential for cardiac conduction abnormalities. (Choice B) Bupropion is a norepinephrine and dopamine reuptake inhibitor that has activating effects and does not cause weight gain. It would likely exacerbate this patient's insomnia and anxiety and contribute to weight loss through loss of appetite. Bupropion is useful in patients with lethargy and sedation, but it should be avoided in those with seizure disorders. (Choice E) Olanzapine is a second-generation antipsychotic that causes side effects of sedation and weight gain. Although it may be used as an augmentation strategy in treatment-resistant depression, it would not be used as first-line monotherapy for depression. Educational objective: Mirtazapine is a first-line antidepressant choice for depressed elderly patients with insomnia, anxiety, and weight loss. __________ References: Mirtazapine versus other antidepressive agents for depression. (http://www.ncbi.nlm.nih.gov/pubmed/22161405) Sertraline and mirtazapine as geriatric antidepressants. (http://www.ncbi.nlm.nih.gov/pubmed/23995195) Review of the use of mirtazapine in the treatment of depression. (http://www.ncbi.nlm.nih.gov/pubmed/21644844)

An 82-Year-Old Woman Comes to the Physician Due to Sadness