For this Discussion, review the case below. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs. 

1. List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.

a. How many hours of sleep do you get per night? – To determine the severity of the patient’s insomnia and whether it meets diagnostic criteria. b. Do you feel refreshed upon awakening? – To understand if the patient is experiencing any symptoms of sleep deprivation. c. Have you tried any sleep aids or remedies? – To assess the effectiveness of any previous treatments and to determine if any non-pharmacological approaches have been tried.

2. Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

a. Family members or close friends – To obtain additional information about the patient’s sleep habits, behavior, and mood before and after the loss of her husband. b. The patient’s primary care provider – To obtain additional information about the patient’s medical history, current medications, and any previous treatments for insomnia or depression. c. A mental health provider – To determine if the patient would benefit from counseling or therapy to address her depression and insomnia.

3. Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.

A physical exam may be appropriate to rule out any underlying medical conditions that could be causing or contributing to the patient’s insomnia. Diagnostic tests, such as a sleep study, may also be useful in diagnosing any underlying sleep disorders. These tests would help to determine the best course of treatment for the patient.

4. List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.

Differential diagnoses for insomnia in an elderly patient could include major depressive disorder, anxiety disorder, substance abuse disorder, and medical conditions such as sleep apnea. The most likely diagnosis in this case is major depressive disorder, as the patient’s insomnia and depression began after the loss of her husband and she has no previous history of depression.

5. List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.

Two pharmacologic agents that may be appropriate for the patient’s antidepressant therapy are selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). The dosing for sertraline, the SSRI the patient is currently taking, may be increased from 100mg to 150-200mg per day. Alternatively, duloxetine, an SNRI, may be initiated at a starting dose of 30mg per day and increased as necessary. Both of these agents increase the levels of neurotransmitters in the brain, which can help to alleviate symptoms of depression and improve sleep.

6. For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?

There are no known contraindications to the use of SSRIs or SNRIs based on ethnicity. However, it is important to consider potential differences in drug metabolism and side effect profiles among different ethnic groups. For example, some studies have suggested that Asians may be more susceptible to certain side effects of SSRIs, such as sexual dysfunction.

7. Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc