A 49-year-old woman comes to the office due to depression. She quit her retail sales job 6 months ago as she could no longer stand all day due to increasing numbness, tingling, and painful, burning sensations in her feet. The patient has since become increasingly depressed, withdrawn, and preoccupied with feelings of low self-esteem. She is unable to concentrate to read or watch television and has lost interest in her family and friends. The patient also describes severe insomnia and extremely low energy. Medical history is significant for obesity, hypercholesterolemia, and type 2 diabetes mellitus. Medications include glipizide and lisinopril. She has no prior psychiatric history. After medical evaluation, major depressive disorder is diagnosed. Which of the following is the most appropriate pharmacotherapy to treat this patient's condition?

Question

A 49-year-old woman comes to the office due to depression.  She quit her retail sales job 6 months ago as she could no longer stand all day due to increasing numbness, tingling, and painful, burning sensations in her feet.  The patient has since become increasingly depressed, withdrawn, and preoccupied with feelings of low self-esteem.  She is unable to concentrate to read or watch television and has lost interest in her family and friends.  The patient also describes severe insomnia and extremely low energy.  Medical history is significant for obesity, hypercholesterolemia, and type 2 diabetes mellitus.  Medications include glipizide and lisinopril.  She has no prior psychiatric history.  After medical evaluation, major depressive disorder is diagnosed.  Which of the following is the most appropriate pharmacotherapy to treat this patient's condition?

Quizplus · Accepted Answer

This patient is suffering from major depression and worsening diabetic neuropathy. Diabetic peripheral neuropathic pain is a distressing and disabling complication that contributes to depression, sleep disturbance, and overall poor quality of life. The serotonin and norepinephrine inhibitor (SNRI), duloxetine, has demonstrated efficacy in treating painful diabetic neuropathy. It can also be used as a first line treatment for depression, making it a preferred choice in this patient. Both SNRIs and tricyclic antidepressants (eg, amitriptyline) have been shown to have analgesic properties apart from their antidepressant effects and have a role in treating neuropathy and other chronic pain conditions. (Choice A) Bupropion is a norepinephrine dopamine reuptake inhibitor that has not shown efficacy in relieving neuropathic pain. It is associated with increased risk of seizures but less weight gain and sexual side effects than selective serotonin reuptake inhibitors (SSRIs). (Choice B) Citalopram is an SSRI. Although commonly used as first-line antidepressants, SSRIs do not have analgesic properties comparable to SNRIs. (Choice D) In patients with depression characterized by insomnia and weight loss, mirtazapine is often preferred due to its sedating and appetite-stimulating properties. It has not been shown to treat painful diabetic neuropathy and would not be a good choice for an obese patient. (Choice E) The antidepressant trazodone is a serotonin modulator that is highly sedating and commonly used in lower doses to target insomnia. It can cause orthostatic hypotension and is associated with the rare but serious side effect of priapism. Educational objective: Serotonin and norepinephrine reuptake inhibitors (eg, duloxetine) have analgesic properties that can be helpful in treating patients with comorbid depression and chronic pain, including painful diabetic neuropathy. References: A review of the clinical utility of duloxetine in the treatment of diabetic peripheral neuropathic pain. (http://www.ncbi.nlm.nih.gov/pubmed/26309404) Duloxetine for treating painful neuropathy, chronic pain or fibromyalgia. (http://www.ncbi.nlm.nih.gov/pubmed/24385423)

A 49-Year-Old Woman Comes to the Office Due to Depression