A 78-year-old man comes to the office due to depressed mood, decreased appetite, difficulty concentrating, and hypersomnia. He has lost interest in his hobby of woodworking and no longer enjoys socializing with friends and family. The patient has no previous psychiatric history. His other medical problems include hypertension, dyslipidemia, type II diabetes, and peripheral neuropathy that has seemed "a lot more painful lately." He takes lisinopril, atorvastatin, metformin, sitagliptin, and pregabalin.
Physical examination shows distal loss of sensation to pinprick, light touch, and vibration in the feet and lower legs bilaterally. Laboratory studies are unremarkable. Based on this presentation, the patient is diagnosed with major depressive disorder.
Which of the following antidepressant medications would be best for this patient?

Question

A 78-year-old man comes to the office due to depressed mood, decreased appetite, difficulty concentrating, and hypersomnia.  He has lost interest in his hobby of woodworking and no longer enjoys socializing with friends and family.  The patient has no previous psychiatric history.  His other medical problems include hypertension, dyslipidemia, type II diabetes, and peripheral neuropathy that has seemed "a lot more painful lately."  He takes lisinopril, atorvastatin, metformin, sitagliptin, and pregabalin.
Physical examination shows distal loss of sensation to pinprick, light touch, and vibration in the feet and lower legs bilaterally.  Laboratory studies are unremarkable.  Based on this presentation, the patient is diagnosed with major depressive disorder.
Which of the following antidepressant medications would be best for this patient?

Quizplus · Accepted Answer

No specific antidepressant has demonstrated superior efficacy over any other; therefore, medication selection should take medical comorbidity into account. Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressant that has demonstrated efficacy in treating painful diabetic neuropathy. Both SNRIs and tricyclic antidepressants have been shown to have analgesic properties, with their analgesic efficacy being unrelated to antidepressant effects. Because duloxetine is also considered a first-line treatment for major depression, it would be a good choice for this patient. Studies have shown that duloxetine improves several chronic pain conditions, including diabetic neuropathy, fibromyalgia, chronic low back pain, and osteoarthritis. In patients with comorbid depression and chronic pain, effective antidepressant treatment can often decrease or resolve the pain. (Choice A) The tricyclic antidepressant amitriptyline is an effective and low-cost option to treat neuropathic pain in younger, healthier patients. However, its anticholinergic side effects and potential cardiac effects would not make it a first choice in a patient of this age and health profile. (Choices C and E) There is less evidence on the effectiveness of selective serotonin reuptake inhibitors in treating pain compared with SNRIs. (Choice D) Mirtazapine is an effective antidepressant with sedating and appetite-stimulating properties that is often preferred in elderly patients with depression characterized by insomnia and weight loss. It would not be a good choice in this patient with hypersomnia, and it has not been shown to treat painful diabetic neuropathy. Educational objective: Serotonin-norepinephrine reuptake inhibitors (eg, duloxetine) possess analgesic properties that make them a preferred choice in patients with comorbid depression and chronic pain, including painful diabetic neuropathy. __________ References: Duloxetine for treating painful neuropathy, chronic pain or fibromyalgia. (http://www.ncbi.nlm.nih.gov/pubmed/24385423) Duloxetine in painful diabetic neuropathy: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/26710221)

A 78-Year-Old Man Comes to the Office Due to Depressed