A 59-year-old man comes to the office due to worsening depression and insomnia since his wife died 7 months ago from cancer. The patient is frequently tearful and is no longer interested in socializing with his married friends. He has attended 3 sessions of supportive psychotherapy and expresses appreciation for the referral because he likes the therapist. However, he continues to feel depressed and is now experiencing severe insomnia. The patient has difficulty falling and staying asleep, frequently lying awake at night thinking about his wife. He feels very guilty about her death and believes that he should have done more for her during her final months. His appetite is poor and he says it is easier to buy prepared foods than cook for himself. Last week, the patient experienced a moment of severe depression in which he briefly thought that he would be better off dead. However, he insists that he would never act on these thoughts. Vital signs are normal. Physical examination is unremarkable aside from a 3.6-kg (8-lb) weight loss since his wife's death. Which of the following is the most appropriate next step in management of this patient?

Question

A 59-year-old man comes to the office due to worsening depression and insomnia since his wife died 7 months ago from cancer.  The patient is frequently tearful and is no longer interested in socializing with his married friends.  He has attended 3 sessions of supportive psychotherapy and expresses appreciation for the referral because he likes the therapist.  However, he continues to feel depressed and is now experiencing severe insomnia.  The patient has difficulty falling and staying asleep, frequently lying awake at night thinking about his wife.  He feels very guilty about her death and believes that he should have done more for her during her final months.  His appetite is poor and he says it is easier to buy prepared foods than cook for himself.  Last week, the patient experienced a moment of severe depression in which he briefly thought that he would be better off dead.  However, he insists that he would never act on these thoughts.  Vital signs are normal.  Physical examination is unremarkable aside from a 3.6-kg (8-lb) weight loss since his wife's death.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Although there is considerable symptom overlap between grief reactions and major depression, this patient's worsening depression is concerning. His symptoms meet the criteria for a major depressive episode and include depressed mood, loss of interest, insomnia, guilt, low energy, weight loss, and thoughts of death. A major depressive episode is diagnosed regardless of an existing precipitant, including bereavement. grief reactions and major depression Appropriate first-line treatment of major depression includes antidepressant medication and psychotherapy. Although selective serotonin reuptake inhibitors are commonly used as a first choice for the treatment of depressive disorders, mirtazapine would be a preferred choice for this patient with poor sleep and appetite. Mirtazapine is a first-line antidepressant medication whose side effects include stimulation of appetite, weight gain, and somnolence. (Choices A, B, and G) This patient's symptoms are more severe and persistent than would be expected in a normal grief reaction. Although he appears to have a good relationship with his therapist, his depression is worsening. Educating the patient about grief, continuing/increasing the frequency of psychotherapy, or adding a grief support group would not adequately address his worsening depressive symptoms (ie, weight loss, marked insomnia, passive suicidal ideation). (Choice C) Tricyclic antidepressants (eg, amitriptyline) are not considered first-line treatment due to significant anticholinergic side effects, orthostatic hypotension, and cardiotoxicity in overdose. (Choice E) Zolpidem is a non-benzodiazepine sleep medication that would not adequately treat this patient's underlying depression. (Choice F) Electroconvulsive therapy is used mainly for patients who do not respond to antidepressants and for severely depressed patients who are catatonic, psychotic, acutely suicidal, or not eating or drinking. This patient's condition is less severe and would benefit from initial antidepressant treatment. Educational objective: Bereaved patients who develop moderate to severe major depression should be considered for treatment with both psychotherapy and antidepressants. Mirtazapine is a preferred choice for patients with marked insomnia and weight loss due to its side effects of appetite stimulation and sedation. References: Symptom and functional traits of brief major depressive episodes and discrimination of bereavement. (http://www.ncbi.nlm.nih.gov/pubmed/26474367) Review of the use of mirtazapine in the treatment of depression. (http://www.ncbi.nlm.nih.gov/pubmed/21644844)

A 59-Year-Old Man Comes to the Office Due to Worsening