What is the most appropriate next step in evaluation for an 18-year-old woman with a 2-month history of poor sleep and fatigue?

From the Guidelines

The most appropriate next step in evaluation for an 18-year-old woman with a 2-month history of poor sleep and fatigue is to screen for major depressive disorder. This approach is based on the fact that the patient's symptoms, including poor sleep, fatigue, and unintentional weight loss, could be indicative of an underlying mental health condition such as depression, which is common in young adults and can significantly impact quality of life and morbidity if left untreated 1. Given the patient's presentation, it is crucial to prioritize the assessment of mental health, as depression and anxiety are prevalent in this age group and can manifest with sleep disturbances and fatigue, thus affecting mortality and quality of life 1. The patient's history of regular menses and the absence of other significant medical findings on physical examination suggest that hormonal imbalances or other chronic medical conditions may be less likely, although basic laboratory tests such as complete blood count, thyroid function tests, and vitamin D levels could still be considered to rule out underlying medical causes 1. However, the immediate next step should focus on assessing and addressing potential mental health issues, given their significant impact on sleep, fatigue, and overall well-being, and the potential to improve quality of life and reduce morbidity and mortality through early intervention 1. Key aspects of the evaluation should include:

• A comprehensive clinical interview to assess sleep patterns, mental health, and potential medical causes.
• Utilization of standardized tools for depression and anxiety screening, such as the PHQ-9 and GAD-7.
• Consideration of lifestyle factors, including sleep hygiene practices, exercise habits, and substance use.
• Maintenance of a sleep diary to monitor sleep patterns and identify potential triggers for sleep disruption. By prioritizing the assessment and management of potential mental health conditions, such as major depressive disorder, the evaluation can be tailored to address the most likely underlying causes of the patient's symptoms, thus optimizing the approach to improve quality of life and reduce morbidity and mortality.

From the Research

Evaluation of Poor Sleep and Fatigue

The patient presents with a 2-month history of poor sleep and fatigue, which has significantly impacted her daily life and ability to work. Given her symptoms and the absence of any acute distress or abnormalities on physical examination, the most appropriate next step in evaluation would be to screen for major depressive disorder.

• The patient's symptoms of poor sleep, fatigue, and unintentional weight loss are consistent with major depressive disorder, as noted in studies 2, 3, 4, 5, 6.
• The U.S. Preventive Services Task Force (USPSTF) and American Academy of Family Physicians recommend screening for depression in the general adult population, including young adults like the patient 2.
• The Patient Health Questionnaire-9 (PHQ-9) is a commonly used and validated screening tool for depression, with a sensitivity and specificity that make it an effective tool for identifying patients who may be at risk for major depressive disorder 2, 5.
• Given the patient's age and symptoms, screening for major depressive disorder using the PHQ-9 or a similar tool would be an appropriate next step in evaluation, as it would help to determine whether her symptoms are related to depression or another underlying condition.

Rationale for Screening

Screening for major depressive disorder is important because it can help identify patients who are at risk for depression and provide an opportunity for early intervention and treatment. The patient's symptoms of poor sleep and fatigue are consistent with depression, and screening would help to determine whether these symptoms are related to an underlying depressive disorder.

• Studies have shown that major depressive disorder is frequently accompanied by sleep disturbances, such as insomnia or hypersomnia, and that these symptoms can persist even after mood symptoms have been adequately treated 4.
• The patient's symptoms of fatigue and sleepiness are also consistent with major depressive disorder, and screening would help to determine whether these symptoms are related to an underlying depressive disorder 6.
• Overall, screening for major depressive disorder is an important step in evaluating the patient's symptoms and determining the best course of treatment.

Next Steps

The most appropriate next step in evaluation would be to screen the patient for major depressive disorder using a validated screening tool, such as the PHQ-9. This would help to determine whether the patient's symptoms are related to an underlying depressive disorder and provide an opportunity for early intervention and treatment.