What should the psych nurse practitioner do for an 81-year-old female with worsening depression, a GDS score of 8, and recently increased levothyroxine, who is currently on Lexapro (escitalopram) 10 mg a day?

Management of Worsening Depression in an Elderly Patient with Hypothyroidism

The psych nurse practitioner should wait to observe the effects of the recent levothyroxine dose increase for at least 2-3 more weeks before considering any changes to the patient's antidepressant regimen.

Assessment of Current Situation

The 81-year-old female patient presents with:

• Stable on escitalopram (Lexapro) 10 mg daily for 3 years
• Subjective complaint of worsening depression
• GDS score of 8 (unchanged from previous month)
• Elevated TSH of 8
• Recent levothyroxine dose increase 3 days ago

Rationale for Waiting Approach

1. Hypothyroidism and Depression Connection

   • Hypothyroidism is a known secondary cause of depressive symptoms 1
   • The patient's elevated TSH (8) indicates suboptimal thyroid function, which may be contributing to her depressive symptoms
   • Recent research shows that increasing levothyroxine dose can improve depressive mood in older adults with hypothyroidism 2

2. Timing Considerations

   • The levothyroxine dose was increased only 3 days ago
   • Thyroid hormone adjustments typically require 4-6 weeks to reach full effect
   • Premature medication changes could lead to overtreatment

3. Stability Assessment

   • The GDS score of 8 is unchanged from the previous month, indicating stable rather than worsening symptoms despite the patient's subjective complaint
   • A GDS score of 8 suggests mild-moderate depression (GDS-SF score ≥ 5 necessitates follow-up) 1

Monitoring Plan

• Schedule a follow-up appointment in 2-3 weeks to reassess depressive symptoms
• Administer the GDS again at follow-up to objectively measure any changes
• Monitor for potential hyperthyroid symptoms that might occur with the increased levothyroxine dose
• Evaluate for clinical improvement in depressive symptoms in response to thyroid optimization

Next Steps Based on Follow-up Assessment

If no improvement after 4-6 weeks of optimized thyroid function:

• Consider increasing escitalopram dose from 10mg to 15-20mg daily
• The American College of Physicians recommends clinical monitoring within 1-2 weeks after any antidepressant dose change 3
• Monitor closely for side effects, particularly in this elderly patient who may be more sensitive to medication changes

Important Considerations

• Age-related factors: At 81 years old, the patient is at higher risk for medication side effects and requires careful monitoring with any medication changes 3
• Drug interactions: Monitor for potential interactions between levothyroxine and escitalopram
• Avoid premature medication changes: Making multiple medication changes simultaneously can confuse the clinical picture and make it difficult to determine which intervention is effective or causing side effects
• Discontinuation symptoms: If changes to escitalopram are eventually needed, be aware of potential discontinuation symptoms which can be more pronounced in elderly patients 4

Caution

• While waiting to observe the effects of thyroid medication adjustment, continue to monitor for any signs of suicidal ideation, as this would warrant immediate intervention regardless of other factors
• If the patient shows any clinical deterioration during the waiting period, earlier reassessment would be indicated