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Old 06-01-2012
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Psyche Treatment of Insomnia!

A 72-year-old woman is evaluated for a 4-month history of insomnia, with difficulty falling asleep. The patient was the major caretaker for her husband, who had advanced heart failure and died suddenly 4 months ago. She has lost 3.6 kg (8 lb) and does not have much of an appetite. The patient used to volunteer at the hospital, but she does not enjoy going there any longer. She also does not have much energy. The patient is tearful and says that nearly everything reminds her of her husband. Medical history is otherwise unremarkable. The physical examination is unremarkable. Which of the following is the most appropriate management option for this patient?

A Begin dextroamphetamine
B Begin mirtazapine at bedtime
C Begin zolpidem at bedtime
D Reassure the patient and schedule a follow-up appointment in 3 months
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Originally Posted by Novobiocin View Post
A 72-year-old woman is evaluated for a 4-month history of insomnia, with difficulty falling asleep. The patient was the major caretaker for her husband, who had advanced heart failure and died suddenly 4 months ago. She has lost 3.6 kg (8 lb) and does not have much of an appetite. The patient used to volunteer at the hospital, but she does not enjoy going there any longer. She also does not have much energy. The patient is tearful and says that nearly everything reminds her of her husband. Medical history is otherwise unremarkable. The physical examination is unremarkable. Which of the following is the most appropriate management option for this patient?

A Begin dextroamphetamine
B Begin mirtazapine at bedtime
C Begin zolpidem at bedtime
D Reassure the patient and schedule a follow-up appointment in 3 months
B..........
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B Begin mirtazapine at bedtime
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Originally Posted by Novobiocin View Post
A 72-year-old woman is evaluated for a 4-month history of insomnia, with difficulty falling asleep. The patient was the major caretaker for her husband, who had advanced heart failure and died suddenly 4 months ago. She has lost 3.6 kg (8 lb) and does not have much of an appetite. The patient used to volunteer at the hospital, but she does not enjoy going there any longer. She also does not have much energy. The patient is tearful and says that nearly everything reminds her of her husband. Medical history is otherwise unremarkable. The physical examination is unremarkable. Which of the following is the most appropriate management option for this patient?

A Begin dextroamphetamine
B Begin mirtazapine at bedtime
C Begin zolpidem at bedtime
D Reassure the patient and schedule a follow-up appointment in 3 months
grief + function loss >2 months...needs treatment...
so it should be b
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Old 06-01-2012
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I'd say D)

It might just be normal bereavement causing all these things..
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Old 06-02-2012
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Originally Posted by tyagee View Post
grief + function loss >2 months...needs treatment...
so it should be b
dont we wait a year for grief & after that it becomes pathological
i know that 2 month is for sever sx only (e.g. illusion
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The most appropriate management option for this patient is to initiate an antidepressant. Between 20% and 30% of spouses experience depression or complicated grief after the loss of a loved one. Most negative symptoms of bereavement peak before 6 months, and most family members are able to resume social activities and other activities of daily living by 6 months after their loved one’s loss. Patients who meet symptoms of major depression for at least 2 consecutive weeks, 8 or more weeks after their loved one’s death, are candidates for pharmacologic therapy.

Major depression in the setting of bereavement cannot be diagnosed unless the symptoms persist for more than 2 months or include substantive functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. In this patient, the symptoms have persisted for more than 2 months and therapy is indicated. Mirtazapine would be an appropriate initial choice in this patient because it is an effective antidepressant and it has a side effect of sedation. Also, weight gain sometimes occurs with mirtazapine, which may be advantageous in a depressed patient with weight loss.

Complicated grief may present as persistent symptoms (>6 months after the loved one’s death) of difficulty accepting the death, feelings of a meaningless future or empty life, difficulty moving on, detachment from other life activities, agitation, bitterness, and difficulty in forming relationships and trusting others. This patient is at risk for complicated grief and should be reassessed in several weeks.

Psychostimulants such as dextroamphetamine have been studied as an initial treatment of depression but with inconsistent efficacy results. Treating the insomnia with zolpidem would not treat the underlying cause of the insomnia. Reassuring the patient and offering follow-up in 3 months do not adequately address the underlying problem, for which there is effective treatment.
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Originally Posted by bisho View Post
dont we wait a year for grief & after that it becomes pathological
i know that 2 month is for sever sx only (e.g. illusion
nope.
function usually returns within 2 months in grief. that what kaplan psych says
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