What is the best course of treatment for a patient, possibly a geriatric patient, presenting with anxiety, depression, insomnia, and visual hallucinations?

Management of Anxiety, Depression, Insomnia, and Visual Hallucinations

First, rule out Charles Bonnet Syndrome (CBS) if the patient has any degree of vision impairment, as education and reassurance alone can resolve the anxiety and hallucinations without requiring antipsychotic medication. 1

Initial Diagnostic Evaluation

Screen for Vision Loss First

• Assess for any degree of visual impairment (reduced acuity, contrast sensitivity, or visual field loss) as CBS is present in 15-60% of patients with ophthalmologic disorders 1
• CBS is characterized by: recurrent vivid visual hallucinations, preserved insight that the hallucinations aren't real, no other neurological diagnosis, and some degree of vision loss 1
• If CBS is confirmed, patient education and reassurance that this is common in visually impaired people leads to significant relief and decreased anxiety 1
• Self-management techniques (eye movements, changing lighting, distraction) can reduce hallucinations 1

Rule Out Medical and Medication Causes

• Review all medications immediately, particularly SSRIs (fluoxetine, paroxetine, sertraline), anticholinergics, steroids, proton pump inhibitors, β-blockers, bronchodilators, corticosteroids, and decongestants, as these commonly cause or exacerbate insomnia and can trigger hallucinations 1, 2, 3
• Obtain comprehensive metabolic panel, CBC, toxicology screen, and urinalysis to exclude metabolic disturbances 2
• Consider brain MRI if hallucinations lack insight, interact with the patient, or have associated neurological signs, as these atypical features suggest Parkinson's disease, dementia with Lewy Bodies, Alzheimer's disease, or structural lesions rather than CBS 1, 2

Assess Suicide Risk Immediately

• Male gender, depression with anxiety comorbidity, and visual hallucinations of deceased relatives indicate high suicide risk 2
• Screen for hopelessness, which strongly predicts suicide risk and treatment dropout 2
• Place patient under one-to-one observation if suicidal ideation is present 2

Treatment Algorithm

For CBS-Related Hallucinations (Vision Loss Present)

1. Provide education and reassurance as first-line treatment - this alone is therapeutic and leads to significant relief 1
2. Teach self-management techniques (eye movements, lighting changes, distraction) 1
3. No pharmacological treatment is recommended for CBS, as there is no significant evidence of efficacy 1
4. Refer for vision rehabilitation and psychological therapy/support groups, which show moderate effect on depression and anxiety in vision loss patients 1

For Anxiety/Depression-Related Hallucinations (No Vision Loss)

1. Initiate SSRI therapy as first-line treatment for the underlying anxiety disorder, which typically resolves hallucinations without requiring antipsychotic medication 2
2. Reserve antipsychotics only for true prodromal psychotic presentations - do not use as first-line for hallucinations in anxiety disorders 2, 4
3. Implement cognitive-behavioral therapy alongside pharmacotherapy 4
4. For acute anxiety or agitation, consider short-term benzodiazepine use cautiously (lorazepam, oxazepam) 1, 4

For Comorbid Insomnia Management

• Address insomnia aggressively, as it predicts new onset hallucinations and worsens anxiety/depression 5, 6
• Evaluate sleep patterns using sleep logs: bedtime, sleep latency, wake after sleep onset, total sleep time, sleep efficiency 1
• Assess daytime activities: napping frequency/timing, caffeine/alcohol consumption, exercise, light exposure 1
• For refractory insomnia after addressing underlying anxiety/depression: use trazodone (25 mg initially, maximum 200-400 mg/day) or mirtazapine (especially if depression and anorexia present) 1
• Avoid benzodiazepines in geriatric patients due to cognitive impairment risk, falls, and paradoxical agitation in 10% of cases 1

Treatment Monitoring

• Reassess depression and anxiety using PHQ-9 and GAD-7 at 4-6 week intervals 2
• Monitor for SSRI treatment response within 4-6 weeks 2
• If hallucinations persist despite SSRI treatment or worsen, reconsider the diagnosis and obtain neurological evaluation 2, 3

Critical Pitfalls to Avoid

• Do not immediately prescribe antipsychotics when hallucinations occur with preserved insight in the context of anxiety/depression 2, 4
• Do not overlook medication side effects - particularly SSRIs, which can cause hallucinations upon discontinuation 7, and proton pump inhibitors, which can trigger acute visual hallucinations 3
• Do not assume psychotic disorder when insight is preserved - this suggests CBS or anxiety-related hallucinations rather than primary psychosis 1, 8
• Do not treat insomnia with benzodiazepines long-term, as this leads to tolerance, addiction, depression, cognitive impairment, and increased fall risk in older adults 1
• Do not miss subdural hematoma or other structural causes in patients with refractory anxiety symptoms unresponsive to standard treatment 3