Depressed elderly w/ poor appetite and sleep, but obese - mirtazapine when?

[caxoo]

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As stated

Patient and family are concerned with sleep and poor appetite but patient is technically either obese or overweight ... what would be your go to?

edit: here, let me make the question more clear

In a patient who is objectively overweight but who has clear concerns for decreased appetite and food intake, what's your approach in regards to the appetite?

 

[theduderino]

there isn't a great literature around the comparative effectiveness of antidepressants. Most of us intuitively reach for medications with side effect profiles that seem like a good match for patient presentations (e.g a medication that is sedating + hunger inducing, in this case) BUT that doesn't mean it's a practice based on high quality trials. With that perspective, I wouldn't overthink the choice of medication. If medication naïve I would use a SSRI. I would also think about a SNRI or TCA (e.g nortriptyline).

 

[deleted1100659]

Poor appetite but obese? Elaborate more on their weight and what they're eating? You can be overweight and not eating but I just wanted to clarify further what you mean, because I hear poor appetite all the time from patients and sometimes it can be a bit questionable..

i would want more details about appetite/sleep

 

[Sikrouf]

There isnt enough information to give an educated answer
Like, at all

 

[Merovinge]

There isnt enough information to give an educated answer
Like, at all

You can't generate the best evidenced based response to psychotropic choice based on 1/3 of a twitter tweet!?

 

[calvnandhobbs68]

Poor appetite but obese? Elaborate more on their weight and what they're eating? You can be overweight and not eating but I just wanted to clarify further what you mean, because I hear poor appetite all the time from patients and sometimes it can be a bit questionable..

i would want more details about appetite/sleep

For real. Poor appetite can mean "I'm eating 2000 calories a day instead of 3000".

 

[comp1]

They've already had a sleep study, I hope?

 

[clausewitz2]

You can't generate the best evidenced based response to psychotropic choice based on 1/3 of a twitter tweet!?

They'll never manage to fit the MDM for 99214 into 30 seconds at this rate.

 

[caxoo]

Poor appetite but obese? Elaborate more on their weight and what they're eating? You can be overweight and not eating but I just wanted to clarify further what you mean, because I hear poor appetite all the time from patients and sometimes it can be a bit questionable..

i would want more details about appetite/sleep

Family concerns that's pt not eating and need to be encouraged to eat

BMI let's say 30

 

[deleted1100659]

Family concerns that's pt not eating and need to be encouraged to eat

BMI let's say 30

What was his weight now vs 1mo ago vs 3 mo vs 6 mo ago vs a year ago? Trends are what matter the most, when you hear not eating, as mentioned above, very subjective. I had a patient last week tell me they "havent slept in 3mos" because their PCP refused to give them zolpidem so they came to see me. He could also simply be eating when others arent around.

another thing is what is his baseline. When did the depression start. Why do you think hes depressed? Whats going on to make him feel this way?

i dont want you to get in the mindset of depression=antidepressant. Its depression=detailed history and then asking yourself what is the likely benefit of medication or is there obvious things that should be addressed first

 

[caxoo]

What was his weight now vs 1mo ago vs 3 mo vs 6 mo ago vs a year ago? Trends are what matter the most, when you hear not eating, as mentioned above, very subjective. I had a patient last week tell me they "havent slept in 3mos" because their PCP refused to give them zolpidem so they came to see me. He could also simply be eating when others arent around.

another thing is what is his baseline. When did the depression start. Why do you think hes depressed? Whats going on to make him feel this way?

i dont want you to get in the mindset of depression=antidepressant. Its depression=detailed history and then asking yourself what is the likely benefit of medication or is there obvious things that should be addressed first

I'd argue that unless symptoms aren't severe enough to cause dysfunction/subjective complaints, or patient is resistant to meds, an approach of ADT + addressing other social issues concurrently is warranted in most cases

I don't have pts weight 1mo ago vs 3mo cause this is a hypothetical lol. Just curious what everyone's approach was. Personally, I'd trend weights and only consider appetite as an issue if weight continues to go down in next ~3 visits, or earlier if family seems extremely concerned with their lack of eating

 

[Crayola227]

I mean, as said, verify he has actual clincal depression. Then treat that, not a specific symptom of it. That's one way people end up on a ton of meds, none of which really help.

Lack of appetite is often very subjective. Rarely, at least in the short term, are patients having lack of appetite that poses significant danger in the short term. Treat the depression, and likely you have improvement in a number of subjective measures.

Keep in mind that to overcome depressive lack of appetite many people will reach for junk food because from a brain science standpoint it's more "rewarding." I would hesitate to give a med that will increase appetite in an already overweight individual if I wasn't also certain it was the best medication for the underlying depression if that is indeed what the issue is. You could end up not treating the depression, increasing appetite, and the patient just eats more Twinkies.

I would explain it to the family as, rather than focusing on one specific symptom, then goal is to treat the underlying disorder. This should improve the symptom. If not, you can always try something else. (perhaps along the lines of making side effects work for you)

 

[Psychresy]

The data indicates weight gain is most prominently seen in post-menapausal women. Might not be as big a factor as you fear in this patient.

 

[FrustratedFamDoc]

Several things to unpack:

Does he say he's not eating or is it a neurotic family (dad's not eating!!!) member that may just need reassurance? Any objective signs of weight loss that you can use to sway your decision?

Treatment naïve? Has anything worked in the past? If so, up to how long ago was it that he on something? How elderly are we talking about?

BMI 30? Co-morbidities that you're worried about if he were to gain 10 lbs? Where I am, 30 is nothing. Going from a 30 to a 32 BMI isn't such a sin if he can look at you with a smile and say thank you doc. I'd take that all day long. It'll be hard/impossible to find anything for mood that does not have potential weight gain associated with it.

 

[Crayola227]

Several things to unpack:

Does he say he's not eating or is it a neurotic family (dad's not eating!!!) member that may just need reassurance? Any objective signs of weight loss that you can use to sway your decision?

Treatment naïve? Has anything worked in the past? If so, up to how long ago was it that he on something? How elderly are we talking about?

BMI 30? Co-morbidities that you're worried about if he were to gain 10 lbs? Where I am, 30 is nothing. Going from a 30 to a 32 BMI isn't such a sin if he can look at you with a smile and say thank you doc. I'd take that all day long. It'll be hard/impossible to find anything for mood that does not have potential weight gain associated with it.

I don't think the issue is, should we be afraid to use a med that may cause weight gain, it's more, should we go out of our way to select a med that is even MORE likely than anything else to increase appetite and might cause weight gain in this overweight depressed individual, because of the report of appetite loss. Otherwise I completely agree with you.

I should have pointed out, that even if the med does improve the depression, which in itself I might expect to improve appetite even without a specific side effect of increasing appetite, that increasing appetite above and beyond that may not be such a great thing.

Absolutely treat the disorder and take the weight gain if you must. Just saying my goal wouldn't be to select a med specifically for increasing appetite in the overweight individual barring some other circumstances (weight loss as mentioned, risk for nutritional deficiency, sig distress from lack of appetite. Etc etc).

Also, I hate to point out, that there could be a lot of reasons you're getting the complaint (neurotic family was given as an example), but some people use food as a mental health coping mechanism in very unhealthy ways, like say binge eating pizza with family, and the depression getting in the way of that might be causing everyone involved to seek care, but it doesn't mean that they should try to get back to status quo.

A less humorous example would be someone who is a sex addict that is suffering ED, and it's causing them distress that they are not able to have sex. If you didn't know about the sex addiction, it would seem obvious that you should just treat the ED so the patient can get back to their sex life. That really makes the most sense if their pre-existing sex life was healthy. If it isn't, then just treating the ED might not be the right thing. They would need treatment for both conditions.

Sometimes patients want to go back to an unhealthy status quo. Change in mental health can prompt seeking care, but rather than just trying to restore a patient back to their "old ways," we should consider what life was like before and if tx and recovery from MH illness rahter than returning them to how they were, could forge a new healthier path forward.

Just my thoughts, some easier said than done.

Which is why this case is better approached with a thorough history and consideration of the whole patient, vs "oh you're not hungry here's a drug with a side effect of increased appetite enjoy your dinner"

 

[caxoo]

Several things to unpack:

Does he say he's not eating or is it a neurotic family (dad's not eating!!!) member that may just need reassurance? Any objective signs of weight loss that you can use to sway your decision?

Treatment naïve? Has anything worked in the past? If so, up to how long ago was it that he on something? How elderly are we talking about?

BMI 30? Co-morbidities that you're worried about if he were to gain 10 lbs? Where I am, 30 is nothing. Going from a 30 to a 32 BMI isn't such a sin if he can look at you with a smile and say thank you doc. I'd take that all day long. It'll be hard/impossible to find anything for mood that does not have potential weight gain associated with it.

When I imagine the picture, I picture a 60-70yo F, around 25-35 BMI, and usually patient isn't concerned about decreased intake although does report it, while family is the ones really concerned with it. The discussion isn't really whether we should shy away from ANY medication treatment, but rather if we should ever go towards treatment that is higher on the weight gain and appetite spectrum

 

[caxoo]

I don't think the issue is, should we be afraid to use a med that may cause weight gain, it's more, should we go out of our way to select a med that is even MORE likely than anything else to increase appetite and might cause weight gain in this overweight depressed individual, because of the report of appetite loss. Otherwise I completely agree with you.

I should have pointed out, that even if the med does improve the depression, which in itself I might expect to improve appetite even without a specific side effect of increasing appetite, that increasing appetite above and beyond that may not be such a great thing.

Absolutely treat the disorder and take the weight gain if you must. Just saying my goal wouldn't be to select a med specifically for increasing appetite in the overweight individual barring some other circumstances (weight loss as mentioned, risk for nutritional deficiency, sig distress from lack of appetite. Etc etc).

Also, I hate to point out, that there could be a lot of reasons you're getting the complaint (neurotic family was given as an example), but some people use food as a mental health coping mechanism in very unhealthy ways, like say binge eating pizza with family, and the depression getting in the way of that might be causing everyone involved to seek care, but it doesn't mean that they should try to get back to status quo.

A less humorous example would be someone who is a sex addict that is suffering ED, and it's causing them distress that they are not able to have sex. If you didn't know about the sex addiction, it would seem obvious that you should just treat the ED so the patient can get back to their sex life. That really makes the most sense if their pre-existing sex life was healthy. If it isn't, then just treating the ED might not be the right thing. They would need treatment for both conditions.

Sometimes patients want to go back to an unhealthy status quo. Change in mental health can prompt seeking care, but rather than just trying to restore a patient back to their "old ways," we should consider what life was like before and if tx and recovery from MH illness rahter than returning them to how they were, could forge a new healthier path forward.

Just my thoughts, some easier said than done.

Which is why this case is better approached with a thorough history and consideration of the whole patient, vs "oh you're not hungry here's a drug with a side effect of increased appetite enjoy your dinner"

It gets more interesting if there is a - how should this be put - a cultural element that sometimes predisposes to overeating/unhealthy eating habits. Granted, I've never had to navigate a discussion where this was ever a source of serious friction and it's always been easily compromisable with family, but I do wonder what I'd say to highly concerned family members who insist that decreased appetite is an issue

 

[Stagg737]

You can't generate the best evidenced based response to psychotropic choice based on 1/3 of a twitter tweet!?

Of course not. We need TikTok for that...

 

[whopper]

You got a patient where they have need of effects a medication provides other than it's usually known main treatment benefits. E.g. Wellbutrin-reduces desire to eat, reduces desire to smoke, antidepressant, also treats ADHD.

So you get a patient with depression, overweight, smokes, and has ADHD. Pick Wellbutrin! But then it's a month later and there's no weight loss, no desire to stop smoking, no desire to reduce eating, no ADHD benefit, and no depression benefit.

Such things can happen, or you can be lucky and all benefits occur, or some occur.

All meds are a crap shoot and might not have the intended effect. In fact one of the reasons why some meds make it to OTC and not prescribe only are cause the OTC ones are more reliable, while the prescribed meds need a doctor to evaluate what happened after it was started and determine if it should be continued (yes of course despite that a lot of docs just spot-check and spend minimum time looking for these things).

 

[clausewitz2]

All meds are a crap shoot and might not have the intended effect. In fact one of the reasons why some meds make it to OTC and not prescribe only are cause the OTC ones are more reliable, while the prescribed meds need a doctor to evaluate what happened after it was started and determine if it should be continued (yes of course despite that a lot of docs just spot-check and spend minimum time looking for these things).

Orrrrrr it's just a question of historical and regulatory happenstance. There is no chance in hell acetaminophen would be approved for OTC in 2022 if it was a novel compound.