What is the most appropriate pharmacotherapy for a 77-year-old woman with symptoms of grief, including difficulty sleeping, decreased appetite, and weight loss, 6 weeks after the death of her husband, with a history of type 2 diabetes mellitus (controlled with glyburide) and hypertension (controlled with verapamil)?

From the Guidelines

The most appropriate approach for this 77-year-old woman experiencing grief symptoms 6 weeks after her husband's death is supportive care and counseling rather than immediate pharmacotherapy. At this stage, her symptoms represent a normal grief reaction rather than a pathological condition requiring medication. Grief typically follows a natural course, and symptoms such as insomnia, decreased appetite, and weight loss are expected during this period. Pharmacological intervention should be considered only if her symptoms persist beyond 2-3 months, worsen significantly, or develop into major depression with suicidal ideation or severe functional impairment.

• Key considerations in her care include:
  • Monitoring for signs of worsening symptoms or development of major depression
  • Regular follow-up to assess her mental status and adjust the care plan as needed
  • Basic sleep hygiene measures to address insomnia, such as establishing a consistent sleep schedule and creating a relaxing bedtime routine
  • Grief counseling and support groups to help her cope with her loss
• Her medical history, including type 2 diabetes mellitus controlled with glyburide and hypertension controlled with verapamil, should be taken into account when considering any future medication choices, as certain antidepressants can interact with these medications 1.
• The focus should be on non-pharmacological interventions that prioritize her quality of life, comfort, and dignity, as outlined in recent guidelines for the care of older adults with diabetes 1.
• If sleep difficulties are particularly troublesome, short-term use of a non-benzodiazepine hypnotic like zolpidem 5mg at bedtime could be considered for 1-2 weeks, but with caution regarding fall risk.
• Ultimately, the decision to initiate pharmacotherapy should be based on a thorough assessment of her symptoms, medical history, and overall well-being, with a focus on minimizing potential harms and maximizing benefits 1.

From the Research

Patient Presentation

The patient is a 77-year-old woman presenting with symptoms of grief, including difficulty sleeping, decreased appetite, and weight loss, 6 weeks after the death of her husband. She has a history of type 2 diabetes mellitus (controlled with glyburide) and hypertension (controlled with verapamil).

Symptoms and Diagnosis

• The patient's symptoms include:
  • Difficulty sleeping through the night
  • Decreased appetite
  • Weight loss of 1.8 kg (4 lb) in 6 weeks
  • Sad mood and tearful affect
  • Frequent thoughts of her deceased husband
  • Episodes of intense longing for her deceased husband
• The patient's physical examination shows no abnormalities, and her mental status examination reveals no evidence of suicidal ideation or hallucinations.

Pharmacotherapy Options

• The patient's symptoms are consistent with grief, but the question of whether pharmacotherapy is indicated is complex.
• Studies have shown that selective serotonin reuptake inhibitors (SSRIs) can be effective in treating depression and anxiety disorders 2, 3, 4, 5.
• However, the patient's symptoms do not necessarily meet the criteria for major depressive disorder (MDD), and the use of SSRIs in grief is not well established.
• Other options, such as trazodone or diazepam, may be considered for the patient's symptoms of insomnia and anxiety, but the evidence for their use in grief is limited.

Most Appropriate Pharmacotherapy

• Based on the available evidence, the most appropriate pharmacotherapy for this patient is not clear.
• However, given the patient's symptoms of grief and the potential for underlying depression or anxiety, a selective serotonin reuptake inhibitor (SSRI) such as escitalopram may be considered, as it has been shown to be effective in treating depression and anxiety disorders 5.
• Alternatively, no pharmacotherapy may be indicated, and the patient may benefit from supportive counseling and education about the signs and symptoms of depression and anxiety 2, 3, 4, 5, 6.

Key Considerations

• The patient's age and medical history should be taken into account when considering pharmacotherapy.
• The potential benefits and risks of pharmacotherapy should be carefully weighed, and the patient should be closely monitored for any adverse effects.
• The use of SSRIs in older adults requires careful consideration of the potential risks, including increased risk of falls, bleeding, and serotonin syndrome 2, 3, 4, 5, 6.