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Replies 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. Post#2 Depression Scenarios by Beatrice Nerettes 1-There is no response to the medication. The purpose of this discussion post is to further elaborate on the course of treatment for Alison. Alison was started on Mirtazapine 7.5 mg at bedtime and reports that she feels the medication is not working after taking the medication for six weeks. My course of treatment plan would be to increase the dosage of mirtazapine from 7.5mg to 15mg at bedtime. “Depressed mood and lack of interest in activities may need up to 6-8 weeks to fully improve” (Mirtazapine (Remeron) n.d). Increase medication dosage and continue to monitor Alison. 2-There is a partial response to the medication. The mood has lifted, but energy and motivation are still poor. Despite Alison reporting partial response to mediation, the mood has lifted, but energy and motivation are still poor. Some essential questions to ask Alison are whether she has experienced an improvement in sleep or appetite, which can be a clear indicator of whether the medication is working. “Sleep, energy, or appetite may show some improvement within the first 1-2 weeks (Mirtazapine (Remeron) n.d). Improvement in these physical symptoms can be an important early signal that the medication is working” (Mirtazapine (Remeron) n.d). If Alison reports increased sleep and appetite, the course of treatment would be to continue with Mirtazapine 15mg-QHS. 3-The mood is improved, but the patient has sexual side effects that interfere with their quality of life. One of the main side effects of taking medications to treat any form of major depression can be decreased libido. Typically, selective serotonin reuptake inhibitors or SSRIs can help lift people out from under a dark cloud of depression, causing decreased interest in sex or even inability to experience orgasm (When an SSRI medication impacts your sex life, 2019). On the contrary, certain antidepressants, such as bupropion, and mirtazapine are less likely to cause sexual problems (When an SSRI medication impacts your sex life, 2019). I would continue Alison on mirtazapine 15mg but provide her with resources to help with improving her sex drive. One suggestion would be for Alison to schedule sex. Often if sex is scheduled before taking medication, it can help with improving sex drive (When an SSRI medication impacts your sex life, 2019). If Alison reports medication interfering with the quality of sex life during our next follow-up appointment, I will prescribe Wellbutrin SR 100mg every morning. One of the main goals of Wellbutrin is to restore the balance of both dopamine and norepinephrine in the brain (Bupropion hcl SR 100 mg tablet,12 hr sustained-release, n.d). Also, individuals prescribed Wellbutrin experience minimal side effects to sex drive. References: Bupropion HCL SR 100 mg tablet,12 hr sustained release. bupropion HCl SR 100 mg tablet,12 hr sustained release | Kaiser Permanente. (n.d.). Retrieved October 9, 2021, from https://healthy.kaiserpermanente.org/health-wellness/drug-encyclopedia/drug.bupropion-hcl-sr-100-mg-tablet-12-hr-sustained-release.208628. Mirtazapine (Remeron). NAMI. (n.d.). Retrieved October 8, 2021, from https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/Mirtazapine-(Remeron). When an SSRI medication impacts your sex life. Harvard Health. (2019, October 22). Retrieved October 9, 2021, from https://www.health.harvard.edu/womens-health/when-an-ssri-medication-impacts-your-sex-life. Reply Posts Instructions 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. Reply separately to two of your classmates’ post (see attached classmates, post#1 and post#2) Your response should include evidence-based research to support your statements using proper citations and APA format. Please, send me the two documents separately, for example one is the reply to my peers Post#1, and the second one is the reply to my other peer Post#2. -Minimum of 300 words per peer reply. -Turnitin Assignment. Background: I live in South Florida; I am currently enrolled in the Psych Mental Health Practitioner Program. I am a Family Nurse Practitioner working in psychiatric area. Post#1: Depression Scenarios by Jimmy Smith The purpose of this discussion is to build on the treatment plan for the video patient from week 5 and describe the treatment plan modifications related to the reported symptoms during the 6 week follow up visit. 1. There is no response to the medication? My rational drug choice for this patient was Sertraline 50mg by mouth daily with increase up to 200mg taper as needed for effect There is no reported response related to depression for the patient at the 6 week follow up. I would continue with the medication after discussing with the patient related to other symptom decrease such as anxiety, quality of life and a overall rating from the patient of whether he feels it is helping. Sertraline may not reduce symptoms of depression at the six week mark as it may not have had time to reach therapeutic level (Lewis, et. al., 2019). Increasing the dosage to 100 mg per day and re-evaluation at next 6 week follow up would be suggested (Woo & Robinson, 2020).. 2. There is a partial response to the medication. Mood has lifted but energy and motivation are still poor. Continue with medication dosage at current dose and suggest group therapy activities and group therapy sessions (Corey, 2017). Addition of group therapy session could increase motivation and allow networking as well as acknowledgement that there are many that suffer from similar symptoms. Learning how others manage symptoms is an important treatment goal for patients with depression (Thimm & Antonsen, 2014). 3. Mood is improved but the patient has sexual side effects that interfere with quality of life. Discussing possible and actual sexual side effects of anti-depressive medications with the patient and gaining an understanding of the extent of sexual dysfunction. It is important to for the patient to make an informed decision on whether to change medications at the 6 week follow up or to continue with current medication for an additional 6 weeks to insure that there is not improvement with dysfunction and with mood. Increasing the mood and overall mental health has been shown to improve joy for patients (Jing & Wilson, 2016). References: Lewis, G., Duffy, L., Ades, A., Amos, R., Araya, R., Brabyn, S., Button, K. S., Churchill, R., Derrick, C., Dowrick, C., Gilbody, S., Fawsitt, C., Hollingworth, W., Jones, V., Kendrick, T., Kessler, D., Kounali, D., Khan, N., Lanham, P., Pervin, J., … Lewis, G. (2019). The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomised trial. The lancet. Psychiatry, 6(11), 903–914. https://doi.org/10.1016/S2215-0366(19)30366-9 Jing, E., & Straw-Wilson, K. (2016). Sexual dysfunction in selective serotonin reuptake inhibitors (SSRIs) and potential solutions: A narrative literature review. The mental health clinician, 6(4), 191–196. https://doi.org/10.9740/mhc.2016.07.191 Woo, T. M., Wynne, A. L., & Robinson, M. V. (2020). Pharmacotherapeutics for Advanced Practice Nurse Prescribers. F.A. Davis Company.