Week 6 reply #2 pharm

Reply Posts

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.

Re: Week 6 Discussion 1: Depression Scenarios

by  Shannon Schaal  - Wednesday, 9 October 2019, 6:01 PM

 

Week 6 Discussion: Depression Scenarios

Scenario #1: There is no response to the medication.

            Before determining if the medication is effective, I would ensure that the patient is taking the medication as prescribed, that there are no underlying medical conditions causing the patient’s symptoms, and that the patient’s psychiatric diagnosis is accurate. After these factors have been assessed, I would then determine medication effectiveness. Therapeutic effectiveness of Zoloft is typically seen within 6-8 weeks (Stahl, 2013). If Zoloft is not working after 6 weeks, providers may want to consider changing the medication (Stahl, 2013). Since the medication is not effective after 6 weeks, I would gradually taper the patient off of the Zoloft. Stahl (2013) suggests that Zoloft should be tapered during discontinuation to prevent withdrawal effects. Navarro (2009) reports that a variety of adverse reactions have been reported with the discontinuation of Zoloft including agitation, insomnia, sleepwalking, dizziness, headache, tremors, anorexia, nausea, fatigue, diarrhea, and ejaculatory delay. Stahl (2013) reports that most patients tolerate a 50% dose reduction for three days, then another 50% reduction for three days, then discontinuation. The patient was prescribed Zoloft 50mg PO daily. Therefore, I would suggest that the patient take Zoloft 25mg PO daily for 3 days, then Zoloft 12.5mg PO daily for 3 days, then discontinue.

            Puzantian and Carlat (2018) report that all SSRIs are equivalent in terms of efficacy. Therefore, I would want to switch the patient to another class of antidepressants. If Zoloft was ineffective, I would switch the patient to Wellbutrin. I would prescribe Wellbutrin XL 150mg PO daily. Puzantian and Carlat (2018) report that with Wellbutrin, you get an effective antidepressant with virtually no sexual side effects, no weight gain, no sedation, and a significant boost in attention. Wellbutrin does not require any routine lab testing for healthy individuals; however blood pressure should be monitored at baseline and periodically throughout treatment (Stahl, 2013). I would recommend for the patient to continue psychotherapy. Cuijpers et al. (2012) report that it is well established that psychiatric medication, as well as psychotherapies, have significant effects on mental health disorders, that both are about equally effective, and that combined treatments are significantly more effective than either psychotherapy or medication management alone. Specifically, I would recommend cognitive behavioral therapy (CBT). Reavell, Hopkinson, Clarkesmith, and Lane (2018) report that CBT allows patients to learn to monitor and improve their psychological well-being by recognizing and challenging unhelpful thinking patterns. The patient would be educated to take the medication exactly as prescribed. The patient would also be educated on all possible side effects of the medication. Before adjusting the medication further, I would wait another 6-8 weeks to determine effectiveness.

Scenario #2: There is partial response to the medication. Mood has lifted, but energy and motivation are still poor.

            As in the first scenario, other factors need to be assessed prior to determining medication effectiveness. Before determining if the medication is effective, I would ensure that the patient is taking the medication as prescribed, that there are no underlying medical conditions causing the patient’s symptoms, and that the patient’s psychiatric diagnosis is accurate. After these factors have been assessed, I would then determine medication effectiveness. If there is a partial response to the medication and mood has lifted, but energy and motivation are still poor, I would consider increasing the dosage. I would increase the dosage from Zoloft 50mg PO daily to Zoloft 100mg PO daily. This dosage remains well under the maximum daily dosage for Zoloft, which is 200mg/day. I would choose to increase the dose rather than change the medication because the patient is having a partial positive response to the medication and SSRIs are clearly less toxic and better tolerated by patients than other antidepressants (Lichtblau, 2011). Zoloft does not require any routine lab testing or monitoring for healthy individuals (Stahl, 2013). I would recommend for the patient to continue psychotherapy. With the dosage increase, I would be vigilant of any adverse side effects since side effects are more likely with an increased dose. I would also monitor for serotonin syndrome. Serotonin syndrome is a potentially life threatening condition associated with the use of multiple or high dose serotonergic agents (Puzantian & Carlat, 2018). Serotonin syndrome is characterized by hallucinations, agitation, variable blood pressure, hyperthermia, hyperreflexia, tachycardia, myoclonus, nausea, vomiting, and diarrhea (Puzantian & Carlat, 2018). The patient would be educated to take the medication exactly as prescribed. The patient would be informed to discontinue the medication and seek treatment immediately if symptoms of serotonin syndrome are identified. The patient would also be educated on all possible side effects of the medication. Before adjusting the medication further, I would wait another 6-8 weeks to determine effectiveness.

Scenario #3: Mood is improved, but the patient has sexual side effects that interfere with quality of life.

            Sexual side effects can have a significant impact on the treatment of depression and can even increase depression levels in many individuals. O’Mullan, Doherty, Coates, and Tilley (2015) report that sexual side effects can impair an individual’s sense of self-worth and negatively affect intimate relationships and quality of life. O’Mullan et al. (2015) further report that it is not surprising that sexual side effects are frequently cited as a reason for non-adherence to medication. Prior to adjusting the medication, I would determine if the sexual dysfunction is related to the antidepressant. If it is determined that the patient is experiencing sexual side effects from the prescribed Zoloft, there are two options for management. The medication can be switched or an additional agent can be added to manage the sexual side effects. Since the patient is having a positive response to the medication, I would add an agent to reduce the sexual side effects. I would add Wellbutrin SR 100mg PO daily. Gitlin, Suri, Altshuler, Zuckerbrow-Miller, and Fairbanks (2002) report that bupropion SR is a significantly effective treatment for SSRI induced sexual side effects for both men and women. Gitlin et al. (2002) further report that prescribing bupropion SR at 100mg daily for the first week to treat SSRI-induced sexual side effects is recommended, increasing the dose up to 300mg daily only if an early response is not seen. Wellbutrin does not require any routine lab testing for healthy individuals; however blood pressure should be monitored at baseline and periodically throughout treatment (Stahl, 2013). The patient would be educated to take the medication exactly as prescribed. The patient would also be educated on all possible side effects of the medication. Before adjusting the medication further, I would wait another 6-8 weeks to determine effectiveness.