W6-Depression Scenarios

6

My Depression Scenarios (Luis Cabrera)

The patient was seen for depression symptoms ranging from lack of energy, difficulties in sleeping, decreased appetite, problems with concentrating, loss of interest in things that she previously enjoyed including struggling with the kids, low sex drive, and intimacy as depicted by difficulties in her relationship with Dave the husband. The patient was managed on sertraline and has come in at six weeks for review. The treatment plans for the three scenarios are discussed herein.  

There is no response to the medication.

The sertraline dosage will be increased from the current 50mg once daily to 100mg once daily for the next four weeks. The currently prescribed dosage is the usually preferred baseline for a client such as Alison who has been diagnosed for the first time. The expectation with the sertraline is that the minimum possible dosage of 50mg daily will trigger the desired serotonin levels and therefore initiate the behavioral changes needed for the client. The pharmacological recommendation is that failure of initial dosage should be followed by an elevation of the dosage to a higher level. For sertraline, the maximum daily dosage for an adult is 200mg (Drugs.com, 2021). However, increments of 50mg on the previous dosage are recommended as opposed to an abrupt increase to 200mg to allow sequential monitoring of the side effects. Thus, Alison will be sustained on an elevated dosage of 200mg sertraline. Notably, the new dosage level will be monitored every week with subjective reporting of the symptoms by the patient. This monitoring is informed by the reality that sertraline may begin to show improvement in symptoms within the first or second week. However, the optimal benefits are attained from week 4 towards week 6 (Williams et al., 2020). Thus, even with minimal or no reported changes in behaviors within weeks 1 and 2, the patient will be encouraged on medication adherence until week 4 when the next clinical visit will be scheduled.

There is a partial response to the medication. Mood has lifted but energy and motivation are still poor.

The patient will be sustained on an elevated dosage of sertraline at 100mg daily (Drugs.com, 2021). Importantly, the extended-release sertraline will be used in place of immediate release sertraline. The partial response by the patient indicates that sertraline is working well for the patient and with no side effects reported the recommendation is to sustain the current medication but alter the dosage. The intention of altering the dosage upwards is to ensure that the serotonin levels are sustained at higher levels to ensure improved mood. Based on the patient’s outcomes herein, the serotonin levels required to achieve improved mood are not being attained with the current dosage of 50mg. Elevating the extended-release dosage to 100mg over the next four weeks will attain two key outcomes; ensure the serotonin levels are maintained at the highest possible levels and over a prolonged period and secondly, ensuring that any possible side effects are gradually monitored to avoid adverse outcomes associated with abrupt dosage elevations. The extended-release sertraline 100mg will be sustained for four weeks. Even for extended release, the maximum benefits are usually identified between weeks 4 and 6. In the first 1-2 weeks, there may be improvements in symptoms, but the maximum effects of the dosage cannot be ascertained (Williams et al., 2020).

Mood is improved but the patient has sexual side effects that interfere with the quality of life.

Alison’s sex life has been affected by both the depression and the side effects of sertraline. Most antidepressants and particularly the SSRIs have a negative impact on the sex drive of an individual by causing low libido (Montejo et al., 2019). Sertraline is among the SSRIs that have a significant impact on libido. Failure to manage the patient’s sex life can adversely affect their esteem and their relationship. For Alison, what she needs right now is minimal stressor factors that may trigger additional debilitating symptoms. Thus, while sertraline has worked well on improving mood, it will be replaced with Bupropion (Wellbutrin) 100mg twice daily for the next 4 weeks. Wellbutrin is as effective as sertraline in the management of most symptoms associated with depression including mood improvements and motivation (Rothmore, 2020). However, Wellbutrin has no sexual side effects as compared to sertraline which has been associated with causing low libido and hence affecting the sex drive of the patient. The patient will also be referred to a sex therapist to help manage the possible relationship issues triggered by the changes in her intimacy levels. Dave, the patient’s husband will be incorporated into the counseling sessions with the sex therapist to enable holistic management of the relationship issues. The intention is to ensure that Dave and Alison interpret the current low intimacy levels as a temporary situation that will change once the treatment plan progresses (Rothmore, 2020). The change of medication to Wellbutrin will also give assurance to the couple that there are expected changes with optimal benefits including the resurgence of the sexual drive at week 4 towards week 6. Medication adherence will be a key emphasis for the patient and will be informed that the best outcomes will be attained with strict adherence patterns (Williams et al., 2020).

References

Drugs.com. (2021). Zoloft Dosage. https://www.drugs.com/dosage/zoloft.html

Montejo, A. L., Prieto, N., de Alarcón, R., Casado-Espada, N., de la Iglesia, J., & Montejo, L. (2019). Management strategies for antidepressant-related sexual dysfunction: a clinical approach. Journal of clinical medicine, 8(10), 1640.

Rothmore, J. (2020). Antidepressant‐induced sexual dysfunction. Medical Journal of Australia, 212(7), 329-334.

Williams, A., Bobrzynski, E., & Koenig, M. E. (2020). In patients with depression, does bupropion reduce anxiety symptoms as well as SSRIs?. Evidence-Based Practice, 23(8), 38-39.