Adult/Geriatric Depression Hispanic Male With MDD.Pharmacological Decisions in the Treatment of Major Depressive DisorderExamine Case Study: An Elderly Hispanic Man With Major Depressive Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client.

QUESTION

Adult/Geriatric Depression

Hispanic Male With MDD

BACKGROUND INFORMATION

The client is a 32-year-old Hispanic American male who came to the United States when he was in high school with his father. His mother died back in Mexico when he was in school. He presents today to the PMHNPs office for an initial appointment for complaints of depression. The client was referred by his PCP after “routine” medical work-up to rule out an organic basis for his depression. He has no other health issues with the exception of some occasional back pain and “stiff” shoulders which he attributes to his current work as a laborer in a warehouse.

SUBJECTIVE

During today’s clinical interview, client reports that he always felt like an outsider as he was “teased” a lot for being “black” in high school. States that he had few friends, and basically kept to himself. He describes his home life as “good.” Stating “Dad did what he could for us, there were 8 of us.” He also reports a remarkably diminished interest in engaging in usual activities, states that he has gained 15 pounds in the last 2 months. He is also troubled with insomnia which began about 6 months ago, but have been progressively getting worse. He does report poor concentration which he reports is getting in “trouble” at work.

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is casually dressed. Speech is clear, but soft. He does not readily make eye contact, but when he does, it is only for a few moments. He is endorsing feelings of depression. Affect is somewhat constricted, but improves as the clinical interview progresses. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment and insight appear grossly intact. He is currently denying suicidal or homicidal ideation. The PMHNP administers the “Montgomery- Asberg Depression Rating Scale (MADRS)” and obtained a score of 51 (indicating severe depression).

RESOURCES

§ Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.

Adult/Geriatric Depression
Hispanic Male With MDD

Decision Point One

Begin zoloft 25 mg orally daily

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Reports a 25% decrease in symptoms
• Client is concerned over the new onset of erectile dysfunction

Decision Point Two

Add augmenting agent such as Wellbutrin IR 150 mg in morning

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client stated that depressive symptoms have decreased even more and his erectile dysfunction has abated
• Client reports that he has been feeling “jittery” and sometimes “nervous”

Decision Point Three

Change Wellbutrin to XL 150 mg orally daily in AM

Guidance to Student
The PMHNP should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as the PMHNP should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect.

To prepare for this Assignment:

• Review this week’s Learning Resources. Consider how to assess and treat adult and geriatric clients requiring antidepressant therapy.

The Assignment

Examine Case Study: An Elderly Hispanic Man With Major Depressive Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

• At each decision point stop to complete the following:
  • Decision #1
    • Which decision did you select?
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
  • Decision #2
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
  • Decision #3
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
• Also include how ethical considerations might impact your treatment plan and communication with clients.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

ANSWER

Pharmacological Decisions in the Treatment of Major Depressive Disorder: A Case Study Analysis

Introduction

In the case study, we examine the treatment decisions for an elderly Hispanic man with major depressive disorder (MDD). The client’s background, subjective complaints, and mental status examination provide valuable insights into his condition. This essay aims to discuss the three decisions made regarding medication prescribing, considering the client’s pharmacokinetic and pharmacodynamic processes. Additionally, ethical considerations in treatment planning and communication with clients will be addressed.

Decision #1: Initiate Zoloft 25 mg orally daily

The first decision was to start the client on Zoloft (sertraline) 25 mg orally daily. This choice aligns with evidence-based guidelines, as SSRIs are considered the first-line treatment for depression (American Psychiatric Association, 2020). Zoloft, a selective serotonin reuptake inhibitor (SSRI), aims to increase serotonin availability in the brain and regulate mood (Stahl, 2013). The expected outcome of Decision #1 was a reduction in depressive symptoms, which was observed as a 25% decrease in symptoms upon the client’s return. However, an unexpected side effect of erectile dysfunction emerged. This emphasizes the importance of monitoring and addressing medication side effects during treatment.

Decision #2: Add Wellbutrin IR 150 mg in the morning

To address the sexual side effects caused by Zoloft, the decision was made to add Wellbutrin (bupropion) IR 150 mg in the morning. Wellbutrin, an atypical antidepressant, enhances norepinephrine and dopamine levels in the brain (Stahl, 2013). This decision aimed to further reduce depressive symptoms and alleviate the erectile dysfunction reported by the client. The client’s depressive symptoms decreased, and erectile dysfunction abated, indicating a positive response to the added medication. However, the client reported feeling jittery and nervous. This difference between expected and actual outcomes can be attributed to the stimulating properties of Wellbutrin IR.

Decision #3: Switch to Wellbutrin XL 150 mg orally daily in the morning

To address the client’s jitteriness and nervousness while maintaining the antidepressant effect, the decision was made to change Wellbutrin to Wellbutrin XL 150 mg orally daily in the morning. Wellbutrin XL is an extended-release formulation that provides a smoother and longer duration of action (Stahl, 2013). This switch aims to optimize the client’s tolerability and minimize side effects. The expected outcome of Decision #3 was a reduction in jitteriness and nervousness. While the specific outcome is not provided, it is anticipated that the extended-release formulation would improve tolerability and offer a more favorable side effect profile.

Ethical Considerations

Ethical considerations play a vital role in the treatment plan and communication with clients. It is crucial to prioritize patient autonomy and involve the client in shared decision-making. Educating the client about the potential benefits and side effects of medications, including their impact on sexual functioning, is essential. Regular monitoring, open communication, and addressing concerns or misconceptions promote a therapeutic alliance. Respecting cultural beliefs and practices while ensuring informed consent further enhance the ethical framework of treatment.

Conclusion

The decisions made regarding medication prescribing for the elderly Hispanic man with MDD involved careful consideration of evidence-based guidelines and the client’s individual needs. Each decision aimed to alleviate depressive symptoms while managing side effects. Ethical considerations, such as patient autonomy and informed consent, were integral to the treatment planning process. By actively monitoring the client’s progress and addressing concerns, healthcare providers can optimize treatment outcomes and promote overall well-being.

References

American Psychiatric Association. (2020). Practice guideline for the treatment of patients with major depressive disorder. Retrieved from https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge University Press.

Decision #1

The decision I selected was to begin Zoloft 25 mg orally daily for the elderly Hispanic man with major depressive disorder. This decision is supported by evidence-based guidelines for the treatment of major depressive disorder. Zoloft, or sertraline, is a selective serotonin reuptake inhibitor (SSRI) that has shown efficacy in treating depressive symptoms (American Psychiatric Association, 2020). SSRIs are considered first-line treatment options for depression due to their established effectiveness and favorable side effect profile.

The goal of initiating Zoloft is to alleviate the client’s depressive symptoms and improve his overall functioning. SSRIs like Zoloft work by increasing the availability of serotonin in the brain, which helps regulate mood and emotions (Stahl, 2013). By targeting serotonin reuptake, Zoloft aims to restore the imbalance in neurotransmitters associated with depression.

In Decision #1, the expected outcome was a reduction in the client’s depressive symptoms. The result of the decision was a 25% decrease in symptoms, indicating a positive response to Zoloft. However, an unexpected side effect emerged, namely erectile dysfunction. Erectile dysfunction is a known side effect of SSRIs and can have a significant impact on the client’s quality of life. This difference between the expected and actual outcome emphasizes the importance of monitoring and addressing medication side effects to optimize treatment outcomes.

Decision #2

The decision I selected was to add an augmenting agent such as Wellbutrin IR 150 mg in the morning. Wellbutrin, or bupropion, is an atypical antidepressant that works by increasing the levels of norepinephrine and dopamine in the brain. Adding Wellbutrin aims to further enhance the antidepressant effect and address the sexual side effects caused by Zoloft (Stahl, 2013).

By introducing Wellbutrin, the goal is to continue reducing the client’s depressive symptoms while mitigating the sexual side effects experienced with Zoloft. Wellbutrin has a different mechanism of action compared to SSRIs and may provide a complementary effect in managing depressive symptoms (Stahl, 2013). It has also been associated with a lower incidence of sexual side effects compared to SSRIs (Montejo et al., 2018).

The expected outcome of Decision #2 was a further decrease in depressive symptoms and an improvement in the client’s sexual function. The result of the decision was a reduction in depressive symptoms and the resolution of erectile dysfunction, indicating a positive response to the addition of Wellbutrin. However, the client reported feeling jittery and nervous. This difference between expected and actual outcomes can be attributed to the stimulating properties of Wellbutrin IR. It is important to consider the specific formulation of Wellbutrin to minimize side effects and optimize tolerability.

Decision #3

The decision I selected was to change Wellbutrin to Wellbutrin XL 150 mg orally daily in the morning. Wellbutrin XL is an extended-release formulation that provides a smoother and longer duration of action compared to the immediate-release formulation. By switching to Wellbutrin XL, the goal is to alleviate the client’s jitteriness and nervousness while maintaining the antidepressant effect of bupropion.

The expected outcome of Decision #3 was a reduction in the client’s jitteriness and nervousness, while preserving the therapeutic benefits of Wellbutrin. The extended-release formulation of Wellbutrin XL ensures a gradual release of the medication, reducing the peak plasma concentration and potentially minimizing side effects such as jitteriness (Stahl, 2013). Although the specific outcome of Decision #3 is not provided in the case study, it is anticipated that the switch to Wellbutrin XL would result in improved tolerability and a more favorable side effect profile.

Ethical considerations play a significant role in the treatment plan and communication with clients. In this case, it is essential to prioritize patient autonomy, respect cultural beliefs and practices, and promote informed consent. It is crucial to educate the client about the potential benefits and side effects of the prescribed medications, including the impact on sexual functioning, and engage in shared decision-making. Regular monitoring, open communication, and addressing any concerns or misconceptions are vital for maintaining a therapeutic alliance and optimizing treatment outcomes.

References

American Psychiatric Association. (2020). Practice guideline for the treatment of patients with major depressive disorder. https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines

Montejo, A. L., Llorca, G., Izquierdo, J. A., Rico-Villademoros, F., & González-Pinto, A. (2018). Incidence of sexual dysfunction associated with antidepressant agents: A prospective multicenter study of 1022 outpatients. Journal of Clinical Psychiatry, 79(2), 17m11367.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge University Press.