The case in question involves a 31-year-old male presenting with a history of depression. He reports history of depressive symptoms along with various life stressors relating to the death of his mother, bullying, and the difficulties associated with living in a non-native country. Like many others, this individual originally sought care for depressive symptoms from a primary care provider, rather than a psychiatrist. Interestingly, from 1996 to 2007, there has been an approximate 15% increase in the number of psychiatric prescriptions dispensed to individuals with no documented psychiatric diagnosis (Mann, 2011). This statistic implies that prescriptions are being written by providers who do not feel comfortable permanently marking an individual’s medical record. One can conclude that a provider who prescribes antidepressants without a documented diagnosis do not specialize in mental illness.
The purpose of this case is to logically decide the medication starting point for a depressed individual, as well as proper action in response to drug effectiveness and patient-reported side effects. Zoloft, Effexor, and Phenelzine are proposed as initial options for treatment of the patient’s depression. In order to decide which medication may be the best starting point for the patient, we must look closely at the class of each drug along with the mechanism of action.
Zoloft belongs to the drug class of selective serotonin reuptake inhibitors (SSRIs). These drugs act to increase the total amount of serotonin in a person’s central nervous system. This action on serotonin has been shown to be highly effective in the treatment of major depressive disorder, along with obsessive-compulsive disorder, panic disorder, PTSD, and social anxiety disorders. These drugs are generally considered to be the preferred first line treatment. However, side effects of Zoloft include sleep changes (either increased sleepiness or insomnia), gastrointestinal symptoms, and decreased sexual functioning. Uniquely, Zoloft is one of very few antidepressants that is known to cause weight loss.
Effexor functions in a manner similar to Zoloft, however, it also effects the concentration of norepinephrine in the central nervous system. Effexor is classified as an SNRI (selective serotonin, norepinephrine reuptake inhibitor). Effexor is typically used to treat the same variety of conditions as described with SSRIs, including depression and disorders based in abnormal anxiety. Side effects of Effexor include sleep changes, abnormal dreams, gastrointestinal issues, sexual deficits, autonomic dysfunction, and seizures. SSRIs and SNRIs are considered to be equally efficacious, with variance in success rates due to personal predisposition to drug response (Zoloft, 2017).
Phenelzine is classified as a monoamine oxidase inhibitor (MAOI). MAOIs cause an overall increase in the neurotransmitters serotonin, norepinephrine, and dopamine. These drugs, however, are known to have significant increases in adverse side effects. Possible side effects include symptoms of over-excitement, such as agitation, hypertension, chest pain, fainting, and potentially hypertensive crisis. Interestingly, use of MAOIs require unique dietary restrictions which are not present for other antidepressant classes. Individuals are restricted from consuming foods high in tyramine, such as aged wines and cheeses. Tyramine can function in the release of catecholamines, leading to the aforementioned side effects. When an MAOI is present, the body is unable to break down tyramine. An adverse reaction to MAOIs can result in life-threatening issues (Nardil, 2017).
Based on the pros and cons of each of the drugs listed, it is easy for a prescriber to eliminate Phenelzine. The risks associated with this drug make it an inappropriate choice as a first-line drug. When deciding between Zoloft and Effexor, we must look into side effects, as the relative efficacy of the drug will not be known until the patient completes a drug trial. This patient reported a recent weight gain of fifteen pounds. Because of this, in addition to overall health risks associated with the patient’s age and ethnicity, the use of Zoloft would be preferred. Zoloft’s potential for weight loss may provide additional benefit to the patient, and makes it slightly more preferred as compared to Effexor (Nardil, 2017; Zoloft, 2017).
The patient returned after four weeks of treatment. At that appointment, he reported a relative decrease in symptoms of 25% with concurrent increases in sexual dysfunction. Research shows that full effect cannot be assessed in antidepressant treatment until six weeks of treatment have been completed (Quitkin, 1984). At this point, the provider should note the patient’s side effects while suggesting the drug trail be completed before medications are changed. The patient was sent home and advised to continue the dosage of Zoloft for a minimum of two more weeks.
At the patient’s visit, occurring an additional four weeks later, the patient reports that he stopped taking the medication due to its sexual side effects. He cannot assess if there was any more improvement in depressive symptoms. At this point, two different courses may be perused, as SSRIs are recommended first-line treatment, we may put the patient back on a 50% dosage of Zoloft with the hopes that the side effects occur in a dose-dependent manner. However, the patient could alternatively be prescribed Wellbutrin. This drug belongs to its own class of antidepressant, has been shown to have the same efficacy rate of SSRIs, and rarely causes sexual side effects. While it may not be advised to change drug classes without confirmed failure of the original treatment, the fact that the sexual side effects experienced by this patient outweigh the negative symptoms of his depression imply that this is a significant concern for the patient. In order to increase the chances that the patient will complete the next drug trial, Wellbutrin should be the next recommended drug. Follow-up should occur in 6-8 weeks (Castleman, 2012).
