Compare your response to two of your peers. Do you agree with their decision making? What are the pros and cons of their choices? What other suggestions might you offer?
Your response should include evidence of review of the course material through proper citations using APA format.
Week 6 Discussion 1: Depression Scenario
The medication I chose for Allison was Sertraline (Zoloft) 50mg po qd (Hirsch & Bimbaum, 2018). If she is having no response to the medication, I will need to see how long she has been on this and review her symptoms. Sleep, energy, and appetite may show some improvement within the first week or two. An early sign that the medication is working is improvement in physical symptoms. Depressed mood and lack of interest in activity may need about six to eight weeks to really see an improvement (NAMI, 2019). With this being said, I would increase Allison’s Sertraline. Patients not responding to a 50 mg dose may benefit from dose increases. Dose changes should be made in steps of 50 mg at intervals of at least one week, up to a maximum of 200 mg/day. Changes in dose should not be made more frequently than once per week given the 24-hour elimination half- life of sertraline (EMC, n.d.). There are no specific medical tests required before starting an SSRI (Hirsch & Bimbaum, 2018). In a study done by Kesim, et al., 2011, blood glucose, insulin, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), and triglyceride values were all measured in patients before, and at the 4th, 8th and 12th weeks after treatment with sertraline. The results of this study showed no changes in the physical exam, (blood pressure, BMI, body weight, height, waist circumference) and laboratory findings (glucose, HDL-C, LDL-C, HOMA-IR and HbA1C levels) at twelve weeks compared to pretreatment values. However, there was a significant increase in insulin levels at the fourth, eighth and twelfth week and triglycerides levels rose in the eighth and twelfth week compared to pretreatment values. With this being said, sertraline-treated patients should to be followed up for blood insulin and triglyceride levels to prevent possible metabolic changes. I do not feel a referral is needed at this time as I would plan on continuing with weekly psychotherapy for Allison and her family. Therapy would include cognitive therapy (for Allison) which usually lasts between six to eighteen weeks. This type of therapy helps people learn to turn negative patterns of thinking into more positive ones, thus improving their mood (Keitner, 2019). I would also include family and couple’s therapy for Allison’s children and her partner. Studies have shown that these types of therapy can improve dysfunction in those families dealing with a member who is depressed. Plus, support from a family member or partner has been shown to decrease the frequency of depression following a stressful life event (Keitner, 2019).
If Allison’s mood has lifted but her energy and motivation was still poor and she was only having a partial response to the Sertraline, I would first need to make sure she was compliant with her treatment regimen before considering augmenting, combining or switching medications (Thase, 2009). This can be done by having the patient complete the Patient Medication Adherence Questionnaire (PMAQ). Another thing that needs to be considered is whether or not she may have some underlying medical condition like hypothyroidism that is not being treated (Gaynes, 2009). Many patients with depression that respond to treatment continue to have significant symptoms. The standard of care in a situation like this is to switch or add an antidepressant or augment with other types of agents (Marin & Menza, 2004). Fatigue is not only a common complaint in primary care, it is a common symptom in depression, a predictor of future depression and a common symptom in treated depressive patients (Marin & Menza, 2004). Serotonergic agents can be a cause of fatigue especially if fatigue was not present or not really an issue at the start of treatment. Managing low energy and motivation can be done by ruling out certain causes like medical issues or medication, looking at certain lifestyle changes, acknowledging fatigue and developing a treatment plan, through regular exercise and if necessary, medication management (Marin & Menza, 2004). In Allison’s case I would prescribe Bupropion XL (Wellbutrin) initial dose of 150 mg once daily in the morning and then increase dose to 300 mg after four days (Stahl, 2017, p. 109), as this medication has an alerting affect, has been proven useful in attention deficit disorders and does not seem to affect the psychomotor performance (Marin & Menza, 2004). Polypharmacy and augmentation have its advantages over-dose increases and switching (monotherapy) strategies. It avoids the loss of therapeutic benefits from the first line agent as well as any risk of withdrawal symptoms that could occur with switching (Papakostas, 2009). Another advantage of augmenting is that it may help resolve depression and depressive symptoms and also target the effects of the first-line agent. Augmenting with an atypical like Bupropion has been the best studied and an effective strategy for managing treatment resistant depression (Papakostas, 2009). Bupropion XL does not require any routine lab testing. The only recommendation is to monitor blood pressure prior to starting medication and periodically during treatment (Stahl, 2017, p. 108). Again, as stated above I do not feel a referral is needed at this time as I would plan on continuing with weekly psychotherapy for Allison and her family.
Allison now has sexual side effects that are interfering with her quality of life. In this situation, I would add another agent because her mood has improved on the Sertraline. I would prescribe Bupropion XL (Wellbutrin) initial dose of 150 mg once daily in the morning and then increase dose to 300 mg after four days (Stahl, 2017, p. 109). Bupropion’s mechanism of action involves blocking the reuptake of norepinephrine and dopamine. Drugs that may improve sexual side effects secondary to SSRIs include bupropion and phosphodiesterase-5 inhibitors (Hirsch & Bimbaum, 2019).Patients with SSRI induced sexual dysfunction do not respond to lower doses or watchful waiting (Hirsch & Bimbaum, 2019). It is suggested to switch antidepressants rather than augment in those that have had considerable benefit from SSRI therapy but have severe sexual dysfunction, or with modest benefit from SSRI therapy and moderate sexual dysfunction (Hirsch & Bimbaum, 2019). Patients treated with SSRIs who obtain substantial relief from the depressive syndrome like in Allison’s case and suffer only moderate sexual dysfunction are typically managed by augmenting the SSRI with a second drug, like phosphodiesterase-5 inhibitors or bupropion. For women with sexual dysfunction, bupropion is recommended at higher doses rather than a phosphodiesterase-5 inhibitor which is a recommended treatment for men with erectile dysfunction (Hirsch & Bimbaum, 2019). Bupropion XL does not require any routine lab testing. The only recommendation is to monitor blood pressure prior to starting medication and periodically during treatment (Stahl, 2017, p. 108). I would continue psychotherapy with Allison and her partner twice a month as needed. The role of this type of therapy is to help them explore their sexual concerns and help them communicate their needs to each other. With certain lifestyle changes such as good sleep practices, reducing stress, exercise and encouraging them to establish regular date nights that they can spend away from family responsibilities, it is possible to have a satisfying sex life while keeping the depression under control (Shifren, 2019).