An older spouse brings her 75-year-old husband to the primar

An older spouse brings her 75-year-old husband to the primary care physician because he no longer has been working in his basement wood shop. He recently underwent radiation therapy for localized prostate cancer. The patient complains of a prolonged history of inability to fall asleep and arising early in the morning. He has not been eating well lately, and his energy level has really fallen off. He has not been doing his daily crossword; in fact, he is not interested in much of anything anymore. His general physical examination, including tests for cognitive function, is normal. Laboratory studies are also un-helpful at establishing the diagnosis. Which of the following would be the most useful systemic therapy?

(A) Haloperidol
(B) Amitriptyline
(C) Methylphenidate
(D) L-Thyroxine
(E) Electroconvulsive therap

C.
Significant depression occurs in up to 10% of older adults and is easily overlooked. The diagnosis requires symptoms to persist for a least 2 weeks and for a patient to exhibit at least four of the following: sleep disturbance, lack of interest, feelings of guilt, decreased energy, decreased concentration, decreased appetite, psychomotor agitation/retardation, and suicidal ideation. Methylphenidate in the morning and at noon can often be associated with a rapid response with a cost of few side effects. Sertaline and desipramine are effective for those with primarily psychomotor retardation, whereas nortriptyline or nefazodone are more useful for those who display agitation. Amitryptyline should be avoided due to the problems of anticholinergic and orthostatic side effects.