Response To Case 1: Volume 2, Case 16: The Woman Who Liked

Response to Case 1: Volume 2, Case #16: The woman who liked late-night TV

This case study provides an insightful look into the multifaceted presentation of depression in an elderly female patient, emphasizing the importance of comprehensive assessment and tailored treatment strategies. The patient's presentation with sadness, sleep disturbances, and a history of medical comorbidities illustrates how depression often interplays with other physiological and psychosocial factors, especially in geriatric populations.

The patient's symptoms, including persistent crying spells, sleep disturbances, and feelings of loneliness, are characteristic of Major Depressive Disorder (MDD), particularly with associated insomnia and possible underlying Restless Leg Syndrome (RLS). The exacerbation of her symptoms due to sleep deprivation is consistent with current research indicating that poor sleep quality can both be a symptom and a precipitant of depression (Al-Abri, 2015). Notably, her familial history of depression further underscores the genetic predisposition component in the pathogenesis of mood disorders (Lohoff, 2010).

A comprehensive assessment remains critical in this case. First, evaluating her sleep pattern using actigraphy and polysomnography can elucidate the presence of RLS and sleep apnea, providing a clearer picture of her sleep architecture and its impact on her mood (Martin & Hakim, 2011; Hein et al., 2017). Additionally, screening for other causes of fatigue and mood disturbance, such as thyroid functioning given her hypothyroidism, is warranted to rule out physiological contributors (Kumar & Clark, 2012).

Psychosocial factors, especially her recent widowhood and social isolation, are significant contributors to her depression. Her loneliness, coupled with limited social interactions, heightens her vulnerability to mood disorders. Engaging her family and caregivers in her treatment plan—specifically her son and home aide—can facilitate ongoing monitoring and support. Open questions regarding her perception of her RLS symptoms, daytime activity levels, and sleep quality can provide valuable subjective data to guide management.

Pharmacological interventions should be selected with caution, particularly considering her age and comorbidities. The proposed use of an SSRI like citalopram (Celexa) is appropriate, with attention to dosing limits to avoid cardiac effects, especially QT prolongation, which is a concern in elderly patients (Stahl, 2008). Starting with a low dose and titrating gradually is advisable. The addition of a non-benzodiazepine hypnotic such as Zaleplon (Sonata) aligns with current guidelines favoring agents with minimal respiratory depression risk, particularly important if sleep apnea is suspected (Stahl, 2008).

Non-pharmacological strategies should be integrated into her treatment plan. Cognitive-behavioral therapy (CBT) tailored for late-life depression has demonstrated efficacy in reducing depressive symptoms and improving sleep quality (Cuijpers et al., 2013). Also, addressing her social isolation through community engagement or support groups can have a positive impact on her mental health, mitigating feelings of loneliness.

In managing geriatric depression, clinicians must remain vigilant about medication side effects, cognitive changes, and the potential for polypharmacy interactions. Regular follow-up to monitor therapeutic response and adverse effects is essential. Multidisciplinary collaboration—between primary care, psychiatry, sleep medicine, and social services—is fundamental to optimizing her outcomes.

References

• Al-Abri, M. A. (2015). Sleep Deprivation and Depression: A bi-directional association. Sultan Qaboos University Medical Journal, 15(1), e4–e6.
• Hein, M., Lanquart, J. P., Loas, G., Hubain, P., & Linkowski, P. (2017). Similar polysomnographic pattern in primary insomnia and major depression with objective insomnia: a sign of common pathophysiology?. BMC Psychiatry, 17(1), 273.
• Lohoff, F. W. (2010). Overview of the genetics of major depressive disorder. Current Psychiatry Reports, 12(6), 539–546.
• Kumar, P., & Clark, M. (2012). Clinical Medicine (8th ed.). Elsevier Saunders.
• Martin, J. L., & Hakim, A. D. (2011). Wrist actigraphy. Chest, 139(6), 1514–1527.
• Stahl, S. M. (2008). Essential Psychopharmacology (Online Ed.). Cambridge University Press.
• Hein, M., Lanquart, J. P., Loas, G., Hubain, P., & Linkowski, P. (2017). Similar polysomnographic pattern in primary insomnia and major depression with objective insomnia: a sign of common pathophysiology?. BMC Psychiatry, 17(1), 273.
• Cuijpers, P., van Straten, A., Andersson, G., & van Oppen, P. (2013). Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology, 81(4), 577–584.
• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
• National Institute for Health and Care Excellence (NICE). (2019). Depression in adults: recognition and management. NICE Guideline [NG222].