To the Editor: Dr Whooley1 described the diagnosis and treatment of depression in adults with comorbid medical conditions. However, several dimensions of treating depression in these therapeutically challenging patients in primary care require comment.
The patient is described as obese with numerous pain problems and treated obstructive sleep apnea (OSA). Although the cardinal symptoms of depression (low mood and anhedonia) are endorsed, the presentation is also one of sleepiness, fatigue, low energy, and a feeling of fogginess. When such symptoms persist despite serial trials of antidepressants, it is imperative to inquire about adherence with the continuous positive airway pressure (CPAP) device. If patients are adherent, they may need to be reevaluated for proper mask fit and adequate positive airway pressure.2 In addition, despite treatment with the CPAP device, patients with OSA may still experience nighttime microarousals and associated daytime neuropsychiatric consequences. Treatment with medication such as modafinil may help these residual symptoms and markedly improve quality of life.