When choosing initial treatment options for depression, the classes of medications have similar efficacy, so it is best to focus on safety and medication tolerance (Rosenthal & Burchum, 2018). Therefore, I chose to start with a Selective Serotonin Reuptake Inhibitor (SSRI), recognized as the safest and most tolerated medications for treating major depression (Rosenthal & Burchum, 2018). The pathophysiology of these medications is unclear; however, the theory suggests that these medications compensate for serotonin deficiency in the synapse (Holck, Wolkowitz, Mellon, Reus, Nelson, Westrin, & Lindqvist, 2019). Serotonin is needed to regulate sleep, mood, and cognition (Holck et al., 2019). By increasing the amount of Serotonin in the synapse, this patient’s depressive symptoms decreased. In the second decision, I chose to add Wellbutrin IR to the patient’s medication regimen to help treat his erectile dysfunction symptoms. Wellbutrin is an atypical antidepressant where the mechanism of action is also not understood (Rosenthal & Burchum, 2018). However, the effects may be related to blocking the reuptake of dopamine, which regulates behavior and influences learning, and norepinephrine, which plays a role in getting the brain and body ready for action (Berke, 2018; Rosenthal & Burchum, 2018). While Wellbutrin helps depression, it also seems to help with sexual desire (Rosenthal & Burchum, 2018). Fortunately, this additional medication helped the patient in the scenario. After four weeks of taking both drugs, he had a continued decrease in depressive symptoms and no longer struggled with sexual dysfunction. In my third decision, I chose to change the Wellbutrin order to extended-release since the patient was experiencing restlessness symptoms. The immediate-release may have been too much, too fast for the patient as it reaches its peak two hours after administration (Rosenthal & Burchum, 2018). Extended-release Wellbutrin reaches its peak at five hours with a half-life of approximately 21 hours (Food and Drug Administration, n.d.). This change will help to settle the experienced side effects of the medication.
Treatment Plan The effect of Zoloft and Wellbutrin on the patient’s pathophysiology will impact the patient’s treatment plan. Common side effects of SSRIs include weight gain, insomnia, sexual dysfunction, and increased risk of suicide (Rosenthal & Burchum, 2018). I already addressed sexual dysfunction by adding Wellbutrin, but the monitoring for the other side effects is also essential for safety and compliance purposes. The patient already has had a significant amount of weight gain and complains about insomnia. Therefore, follow up appointments are necessary for close monitoring of these possible side effects. Treatment should include education about proper diet and activity to regulate weight. The provider should also assess the patient’s sleep to ensure the medication is helping rather than worsening the amount and quality of sleep. It is also crucial for the provider to educate the patient on the increased risk of suicide and encourage the patient to seek help immediately if he starts having these thoughts. The provider should assess the patient for suicidal ideation frequently.
Wellbutrin is usually well tolerated; however, it carries a risk for seizures and psychotic symptoms. Therefore, the provider should assess for any seizure risk factors such as a history of seizures, a head injury, an eating disorder, or a CNS tumor (Rosenthal & Burchum, 2018). The provider should also assess the patient for psychotic symptoms at each follow-up visit, such as hallucinations or delusional thoughts (Rosenthal & Burchum, 2018).
Berke, J.D. (2018). What does dopamine mean? Nature Neuroscience, 21(6), 787-793. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29760524Food and Drug Administration. (n.d.). Wellbutrin XL. Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/021515s026s027lbl.pdfHolck, A., Wolkowitz, O. M., Mellon, S. H., Reus, V. I., Nelson, J. C., Westrin, Å., & Lindqvist, D. (2019). Plasma serotonin levels are associated with antidepressant response to SSRIs. Journal of Affective Disorders, 250, 65–70. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jad.2019.02.063Laureate Education (Producer). (2019). Adult geriatric depression [Interactive media file]. Baltimore, MD: Author.Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.