What is the most appropriate pharmacotherapy for a 69-year-old man with a 3-month history of depression, anxiety, and insomnia, who has a history of gastroesophageal reflux disease (GERD), benign prostatic hyperplasia (BPH), cerebral infarction with related seizure disorder, and myocardial infarction, and is currently taking atorvastatin, tamsulosin, famotidine, lamotrigine, and daily aspirin?

From the Guidelines

For this 69-year-old man with depression, anxiety, and insomnia, sertraline (50 mg daily) would be the most appropriate pharmacotherapy. This selective serotonin reuptake inhibitor (SSRI) has a favorable side effect profile and minimal drug interactions with his current medications, including atorvastatin, tamsulosin, famotidine, lamotrigine, and daily aspirin 1. Sertraline addresses both depression and anxiety symptoms while having minimal impact on his GERD, BPH, seizure disorder, and cardiovascular conditions.

Key Considerations

• The patient's history of myocardial infarction and cerebral infarction with related seizure disorder necessitates careful selection of an antidepressant with minimal cardiovascular risks.
• SSRIs, such as sertraline, are well-studied in patients with coronary heart disease and heart failure, and appear to be safe, although their efficacy in treating comorbid depression and anxiety is mixed 1.
• Sertraline has been shown to have a lower risk of QTc prolongation compared to other SSRIs like citalopram or escitalopram, making it a safer choice for patients with cardiovascular disease 1.
• The medication should be started at a low dose (25 mg daily) for one week before increasing to 50 mg to minimize initial side effects.
• Regular follow-up is essential to monitor response and side effects.

Alternative Options

• Mirtazapine could be considered as an alternative if sleep disturbance is particularly problematic, as it offers additional benefits including appetite stimulation and may be used for sleep 1.
• Cognitive behavioral therapy for insomnia (CBT-I) should be recommended first for insomnia, with short-term use of non-benzodiazepine sleep aids like low-dose trazodone (25-50 mg) if necessary, as benzodiazepines could increase fall risk and potentially interact with lamotrigine 1.

Important Safety Considerations

• Tricyclic antidepressants and monoamine oxidase inhibitors should be avoided due to their significant cardiovascular side effects, including hypertension, hypotension, and arrhythmias 1.
• Benzodiazepines, such as lorazepam, should be used with caution due to the risk of cognitive impairment, fall risk, and potential interaction with lamotrigine 1.

From the FDA Drug Label

Sertraline is a prescription medicine used to treat depression It is important to talk with your healthcare provider about the risks of treating depression and also the risks of not treating it. Sertraline is also used to treat: Major Depressive Disorder (MDD)

The most appropriate pharmacotherapy for the patient is Sertraline (D), as it is used to treat depression, which is one of the patient's symptoms. The patient's symptoms of increased fatigue, severe insomnia, difficulty concentrating, and making decisions are consistent with depression.

• Key points:
  • The patient has a history of depression symptoms
  • Sertraline is used to treat Major Depressive Disorder (MDD)
  • The patient's current medications and medical history do not contraindicate the use of sertraline 2

From the Research

Patient Presentation

The patient is a 69-year-old man presenting with a 3-month history of increased fatigue, severe insomnia, difficulty falling asleep, and waking up at 4:00 AM each day. He also reports being more forgetful, having difficulty concentrating and making decisions, and has stopped engaging in his favorite hobby due to a lack of motivation.

Medical History

The patient has a history of:

• Gastroesophageal reflux disease (GERD)
• Benign prostatic hyperplasia (BPH)
• Cerebral infarction with related seizure disorder
• Myocardial infarction

Current Medications

The patient is currently taking:

• Atorvastatin
• Tamsulosin
• Famotidine
• Lamotrigine
• Daily aspirin

Appropriate Pharmacotherapy

Based on the patient's presentation and medical history, the most appropriate pharmacotherapy for his depression, anxiety, and insomnia is:

• Sertraline 3, 4, 5, a selective serotonin reuptake inhibitor (SSRI) that has been shown to be effective in treating depression and anxiety disorders, with a favorable side effect profile and low risk of pharmacokinetic drug interactions.

Key Points

• Sertraline has been found to be effective in treating depression and anxiety disorders, including generalized anxiety disorder (GAD) 6.
• It has a favorable side effect profile and low risk of pharmacokinetic drug interactions 3, 4.
• Sertraline is considered a first-line treatment for anxiety and depressive disorders 3, 4.
• The patient's current medications do not appear to interact with sertraline, making it a suitable choice for his treatment.

Comparison to Other Options

• Amitriptyline is a tricyclic antidepressant that may have more side effects and interactions compared to sertraline 5.
• Bupropion may be considered as an alternative or adjunctive treatment, but its combination with sertraline may be more effective in refractory depression 7.
• Lorazepam is a benzodiazepine that may be used for short-term treatment of anxiety, but it is not recommended for long-term use due to its potential for dependence and withdrawal.
• Zolpidem is a sedative-hypnotic that may be used for short-term treatment of insomnia, but it is not recommended for long-term use due to its potential for dependence and withdrawal.