What treatment should be started for a 69-year-old male with a history of insomnia, currently taking trazodone (trazodone) 50mg, residing in a long-term care facility, who expresses depression and a wish to die without suicidal ideation (SI) or homicidal ideation (HI)?

Treatment Recommendation for Depression in Long-Term Care Setting

Start an SSRI (such as sertraline or citalopram) at the lowest available dose for this 69-year-old male with depression and passive death wishes, while maintaining close monitoring during the first 2 weeks of treatment. 1

Rationale for Antidepressant Initiation

This patient presents with clear depressive symptoms (expressed wish to die, not wanting to be in the facility, depressed mood) that meet criteria for treatment, even without active suicidal ideation. 1

• Depression is the primary target: Approximately 90% of individuals who express suicidal thoughts suffer from a treatable psychiatric disorder, most commonly a mood disorder, and the longer time spent in a depressive episode, the higher the risk of suicide. 1

• Antidepressants reduce suicide risk: Studies demonstrate that antidepressant treatment decreases the risk for suicidality among depressed patients overall. 2

Specific Medication Selection

First-line choice: SSRI (sertraline or citalopram)

• The American College of Physicians guideline establishes that second-generation antidepressants (including SSRIs) are effective for treating depressive disorders in adults. 1

• For patients 65 years or older, clinicians should be aware of increased risk for upper GI bleeding with SSRIs, particularly when combined with NSAIDs or aspirin. 1 However, this risk does not contraindicate their use—it requires awareness and potentially avoiding concurrent NSAID use.

• Start at the lowest available dose to minimize side effects in this elderly patient. 1

Critical Monitoring Requirements

The first 10-14 days require careful monitoring:

• The risk of suicidal behavior in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. 2

• Schedule follow-up within 1 week of initiation, then again at 2 weeks to assess for any worsening of suicidal thoughts or emergence of active suicidal ideation. 2

Adjunctive Considerations

Short-term anxiolytic/hypnotic support:

• Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended during the acute phase. 2

• However, the current trazodone 50mg can be continued for insomnia as evidence supports trazodone's efficacy for antidepressant-associated insomnia, with studies showing it increases total sleep time and sleep efficiency. 3

What NOT to Do

Avoid treating only the insomnia while ignoring the depression:

• Trazodone alone is insufficient for this patient because the American Academy of Sleep Medicine does not recommend trazodone as first-line therapy for chronic insomnia when used alone, and it has relatively weak evidence for efficacy as monotherapy. 4

• The underlying depression is the primary problem driving both the insomnia and the passive death wishes. 1

Do not delay treatment waiting for psychiatric consultation:

• While multidisciplinary involvement is preferable, primary care physicians can and should initiate antidepressant therapy for depression. 1

• Psychiatric consultation is indicated primarily for patients exhibiting clear self-injury risk with expressed suicide intent or an overt plan for death. 5 This patient denies SI/HI.

Family and Psychosocial Support

• The patient should be motivated to involve family in the treatment, as family involvement improves outcomes. 2

• Address the psychosocial stressor of unwanted long-term care facility placement through social work involvement and exploration of alternative living arrangements if feasible. 2

• Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships and lack functioning social networks. 2

Common Pitfalls to Avoid

• Do not dismiss passive death wishes as "normal" for elderly patients in long-term care—these statements represent significant depressive symptoms requiring treatment. 1

• Do not rely solely on trazodone dose escalation—this addresses the symptom (insomnia) but not the underlying disease (depression). 4, 6

• Do not forget to reassess after 7-10 days—if insomnia or depression worsens despite treatment, this may indicate an underlying sleep disorder or treatment-resistant depression requiring specialist evaluation. 7