Perspectives on the Management of Vascular Depression

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Geriatric Psychiatry, Mood Disorders-Unipolar

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“Mr. A,” an 80-year-old married man, presents for his first psychiatric evaluation. He arrives punctually, carrying a manila folder containing documents summarizing his medication history and previous surgical procedures. He reports that this outpatient visit was initiated by a referral from his primary care physician after his wife expressed concern that her husband appeared to be depressed. Mr. A denies any previous mental health problems, history of psychotropic medication use, or history of therapy. He reports a period of bereavement after the death of his first wife at age 40 but states that he recovered over time without intervention. He remarried 17 years ago and describes his wife as supportive. He previously worked in an executive position that required substantial travel overseas. The development of angina on these trips ultimately resulted in the placement of multiple cardiac stents, and he retired 12 years ago because of health concerns. He has been less active since retirement, and he states that he has no hobbies. He reports that he still ruminates a great deal about events that occurred during his career.

When asked about depressive symptoms, Mr. A does not agree that he is depressed and questions the need for the referral. He admits to feeling socially detached, with a loss of interest and lack of motivation, and states, “I know that I should get out more, but I can’t ever get past the first step.” While he denies feeling overtly sad, he reports feeling irritable at times toward his family, which he finds troubling. According to his wife, Mr. A’s irritability is increasing in frequency and tends to arise without substantive provocation. His sleep is suboptimal, with frequent nighttime awakening due to nocturia, and difficulty returning to sleep. His appetite is adequate, but his weight has been slowly increasing, which he attributes to his sedentary lifestyle. He feels his memory is “okay,” noting that he occasionally has trouble finding the right word to use and that it is harder for him to focus when reading or paying the bills. He reports that his energy is low, and he blames this symptom on his cardiologist’s prescriptions for lisinopril and metoprolol. Overall, he ascribes his difficulties to increased medical problems over the past decade and a corresponding increase in medications. These medications now include atorvastatin for hypercholesterolemia and glipizide for type 2 diabetes in addition to antihypertensives, clopidogrel, and aspirin. He denies feelings of hopelessness and helplessness, but he reports that he sometimes feels discouraged at the change in his ability to function relative to his earlier years. He denies suicidal ideation but casually admits to worries that in the future he could become a burden if he experiences another serious cardiac event.

A comprehensive interview was conducted to assess not only Mr. A’s current symptoms but also factors contributing to his social isolation. During the interview, Mr. A identified some activities that he may take up, including a return to working out in a gym. He noted that when he was young, he was quite conscientious about attending a gym, but this activity was sidelined during his executive years. He was receptive to the idea of restarting a regular workout program and had a senior discount for a gym membership in his neighborhood. A comprehensive review of his sleep-wake cycle suggested that he tended to spend a lot of time at the computer in the evening, out of boredom. He was advised to reduce exposure to light in the evening and begin taking melatonin at bedtime to help stabilize his day-night cycle and increase the restfulness of his sleep. Additional management included the initiation of sertraline, at 25 mg every morning initially, increasing to 50 mg with a plan to further titrate the dosage if well tolerated and needed. He was instructed to focus on positive health behaviors, including resuming regular physical activity, engaging more with his wife’s community activities, and maintaining a healthy diet. He was advised to focus on finding meaningful activities, and he was cautioned to avoid the expectation that medications alone would resolve his symptoms. Mr. A’s wife actively supported the treatment plan, offering to provide assistance in observing his irritability, sleep, and daily activities. Over the following months, Mr. A was able to see improvement in his motivation and was able to resume some remodeling projects. Ultimately, he was able to maintain a regular gym schedule, which, together with melatonin, resulted in improved sleep and well-being.

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Citation / Publisher Attribution

The American Journal of Psychiatry, v. 175, issue 12, p. 1169-1175