Adult/Geriatric Depression
Hispanic Male With MDD

Hispanic male

 

Decision Point One


Begin Effexor XR 37.5 mg orally daily

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what the PMHNP should do next:


Increase dose to 75 mg of Effexor XR orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports an improvement in depressive symptoms
  • Montgomery- Asberg Depression Rating Scale (MADRS) decreased from 51 to 38 (25% reduction)
Decision Point Three
Select what the PMHNP should do next:


Increase dose to 112.5 mg orally daily
Guidance to Student
At this point, the PMHNP would have two choices to discuss with the client- the current dose of drug can be maintained if the client is feeling better and is not offering any complaints of side effects. The dose can also be increased at this point, but the PMHNP must counsel client regarding the possibility of side effects. The use of an augmenting agent is not appropriate at this time as we have not reached a maximum dose with Effexor (in fact, 75 mg is still a relatively small dose), displaying primarily SSRI properties only (recall that at lower doses, Effexor exerts a greater effect on serotonergic receptors than norepinephrine at low doses).
Continue same dose of medication
Guidance to Student
At this point, the PMHNP would have two choices to discuss with the client- the current dose of drug can be maintained if the client is feeling better and is not offering any complaints of side effects. The dose can also be increased at this point, but the PMHNP must counsel client regarding the possibility of side effects. The use of an augmenting agent is not appropriate at this time as we have not reached a maximum dose with Effexor (in fact, 75 mg is still a relatively small dose), displaying primarily SSRI properties only (recall that at lower doses, Effexor exerts a greater effect on serotonergic receptors than norepinephrine at low doses).
Augment with Wellbutrin XL 150 mg orally daily
Guidance to Student
At this point, the PMHNP would have two choices to discuss with the client- the current dose of drug can be maintained if the client is feeling better and is not offering any complaints of side effects. The dose can also be increased at this point, but the PMHNP must counsel client regarding the possibility of side effects. The use of an augmenting agent is not appropriate at this time as we have not reached a maximum dose with Effexor (in fact, 75 mg is still a relatively small dose), displaying primarily SSRI properties only (recall that at lower doses, Effexor exerts a greater effect on serotonergic receptors than norepinephrine at low doses).
Change to Cymbalta 30 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports that his depressive symptoms are “not really any better”
  • Client has noticed that his back pain and shoulder stiffness have improved, which he was not expecting
  • Client is asking if he could be kept on the current medication due to its favorable effect on his pain
Decision Point Three
Select what the PMHNP should do next:


Continue current dose of Cymbalta
Guidance to Student
Maintaining the current dose would be appropriate if the client were showing an improvement in depressive symptoms, but since he is not showing improvement, something needs to be done. Increasing Cymbalta to 60 mg orally daily would be the most appropriate choice as 30 mg is a small dose, and with an effective dose range of 60 to 120 mg orally daily, it would be prudent to increase the client’s dose to a therapeutic dose. Changing to Elavil, a tricyclic antidepressant is not the best choice as it can be associated with increased side effects and although it can treat pain symptoms as well, there is no indication that changing drug therapy at this point would be appropriate as we have not trialed the client with an adequate duration or dose of Cymbalta. It is always beneficial when we can select medications that will treat co-morbid conditions. So Cymbalta should be trialed at an appropriate dose for an appropriate duration to treat the clients pain and depression.
Increase Cymbalta to 60 mg orally daily
Guidance to Student
Maintaining the current dose would be appropriate if the client were showing an improvement in depressive symptoms, but since he is not showing improvement, something needs to be done. Increasing Cymbalta to 60 mg orally daily would be the most appropriate choice as 30 mg is a small dose, and with an effective dose range of 60 to 120 mg orally daily, it would be prudent to increase the client’s dose to a therapeutic dose. Changing to Elavil, a tricyclic antidepressant is not the best choice as it can be associated with increased side effects and although it can treat pain symptoms as well, there is no indication that changing drug therapy at this point would be appropriate as we have not trialed the client with an adequate duration or dose of Cymbalta. It is always beneficial when we can select medications that will treat co-morbid conditions. So Cymbalta should be trialed at an appropriate dose for an appropriate duration to treat the clients pain and depression.
Discontinue Cymbalta and begin Elavil 25 mg orally daily
Guidance to Student
Maintaining the current dose would be appropriate if the client were showing an improvement in depressive symptoms, but since he is not showing improvement, something needs to be done. Increasing Cymbalta to 60 mg orally daily would be the most appropriate choice as 30 mg is a small dose, and with an effective dose range of 60 to 120 mg orally daily, it would be prudent to increase the client’s dose to a therapeutic dose. Changing to Elavil, a tricyclic antidepressant is not the best choice as it can be associated with increased side effects and although it can treat pain symptoms as well, there is no indication that changing drug therapy at this point would be appropriate as we have not trialed the client with an adequate duration or dose of Cymbalta. It is always beneficial when we can select medications that will treat co-morbid conditions. So Cymbalta should be trialed at an appropriate dose for an appropriate duration to treat the clients pain and depression.
Augment with an atypical antipsychotic

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports that he has gained about 9 pounds in the past month
  • Client states that his depression was a little better but his self-esteem is worsening as he is gaining weight
Decision Point Three
Select what the PMHNP should do next:


Discontinue atypical antipsychotic
Guidance to Student
At this point, discontinuation of the atypical antipsychotic would be appropriate. It has contributed minimally to the client’s depressive symptoms, but has instead, decreased self-esteem due to weight gain. Weight gain associated with atypical antipsychotics can also represent a health issue due to its contribution to dyslipidemia, and hyperglycemia. Increasing the dose would most likely worsen these symptoms. If an atypical antipsychotic were needed to augment the antidepressant medication, it would be appropriate to counsel client about diet and exercise to decrease weight gain associated with atypical antipsychotic usage. However, antipsychotics should be discontinued and the PMHNP should counsel client to help with weight loss caused by the atypical antipsychotic.
Increase dose of atypical antipsychotic
Guidance to Student
At this point, discontinuation of the atypical antipsychotic would be appropriate. It has contributed minimally to the client’s depressive symptoms, but has instead, decreased self-esteem due to weight gain. Weight gain associated with atypical antipsychotics can also represent a health issue due to its contribution to dyslipidemia, and hyperglycemia. Increasing the dose would most likely worsen these symptoms. If an atypical antipsychotic were needed to augment the antidepressant medication, it would be appropriate to counsel client about diet and exercise to decrease weight gain associated with atypical antipsychotic usage. However, antipsychotics should be discontinued and the PMHNP should counsel client to help with weight loss caused by the atypical antipsychotic.
Counsel client about diet and exercise
Guidance to Student
At this point, discontinuation of the atypical antipsychotic would be appropriate. It has contributed minimally to the client’s depressive symptoms, but has instead, decreased self-esteem due to weight gain. Weight gain associated with atypical antipsychotics can also represent a health issue due to its contribution to dyslipidemia, and hyperglycemia. Increasing the dose would most likely worsen these symptoms. If an atypical antipsychotic were needed to augment the antidepressant medication, it would be appropriate to counsel client about diet and exercise to decrease weight gain associated with atypical antipsychotic usage. However, antipsychotics should be discontinued and the PMHNP should counsel client to help with weight loss caused by the atypical antipsychotic.