Angela is a 54-year-old married woman with three adult children.

Case Study: CNS Prescriber Drug Therapy Plan for Depression
Read the case study below and create a CNS Prescriber Care drug therapy plan for the patient with Depression.
The patient presents to the clinic today for an annual checkup.
Complaint: fatigue
History: Angela is a 54-year-old married woman with three adult children. She has been the office manager of a small law firm for 20 years and has enjoyed her work until this past year. She has rheumatoid arthritis with minimal impairment that has been managed well with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). She has been taking conjugated estrogens for 8 years and decided to stop taking them because of her concern of their risks without sufficient medical benefit. She has tolerated the discontinuation without difficulty.
Assessment: At her annual medical checkup appointment, she reports feeling tired all of the time, and she was gaining weight because she had no interest in her usual exercise activities and had been overeating, not from appetite but out of boredom. She denied that she and her husband have had marital difficulties beyond the ordinary and she was pleased with the achievements of her children. She noticed that she has difficulty falling asleep at night and awakens around 4 a.m. most mornings without her alarm and cannot go back to sleep even though she still feels tired. She finds little joy in her life but cannot pinpoint any particular concern. Although she denies suicidal feelings, she does not feel that there is meaning to her life: “My husband and kids would go on fine if I died and probably would not miss me that much.” The CNS asks Angela to fill out a Beck’s Depression Scale, which indicates that she has moderate depression.
Answer the following questions related to this case study. Cite at least 3 current, peer-reviewed, scholarly sources in your answers and include a reference list. Cite at least one drug information resource (i.e., UpToDate, Micromedex, Lexicomp).
What classes of drugs are used in the management of depression? .
What would be the initial pharmacotherapy management plan for the patient’s depression?
What are the monitoring parameters for a patient receiving an antidepressant?
At the follow-up visit the patient reports no improvement in symptoms and states she stopped taking the citalopram (Celexa) because it wasn’t working. What additional information does the patient need regarding the achievement of results from an SSRI?
The patient complains of morning nausea and vertigo while taking citalopram. What would be another pharmacotherapy treatment option?
How soon should the patient return to the clinic after the change in medication for follow-up of drug effectiveness?
After taking 2 weeks of escitalopram (Lexapro), Angela returns to the clinic for a follow-up visit. She states that she does not feel much different but may be less tired. She reports that the nausea and vertigo she experienced with citalopram has not occurred with escitalopram. What would be the next step in treatment?
At what point should the provider consider tapering Angela off the SSRI therapy?
Prepare a CNS Prescriber Drug Therapy Plan for the patient in this case study. See attached tool for completion.

ANSWER
What classes of drugs are used in the management of depression?

There are several classes of drugs used in the management of depression, including:

Selective serotonin reuptake inhibitors (SSRIs): SSRIs are the most commonly prescribed class of antidepressants. They work by increasing the levels of serotonin in the brain. Examples of SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).
Serotonin-norepinephrine reuptake inhibitors (SNRIs): SNRIs work by increasing the levels of both serotonin and norepinephrine in the brain. Examples of SNRIs include venlafaxine (Effexor) and duloxetine (Cymbalta).
Tricyclic antidepressants (TCAs): TCAs are an older class of antidepressants that are not as commonly prescribed as SSRIs or SNRIs because they have more side effects. However, TCAs can be effective for patients who do not respond to other antidepressants. Examples of TCAs include nortriptyline (Pamelor), amitriptyline (Elavil), and desipramine (Norpramin).
Atypical antidepressants: Atypical antidepressants are a diverse group of drugs that work in different ways to improve mood. Examples of atypical antidepressants include bupropion (Wellbutrin), mirtazapine (Remeron), and trazodone (Desyrel).
What would be the initial pharmacotherapy management plan for the patient’s depression?

The initial pharmacotherapy management plan for the patient’s depression would include starting her on an SSRI, such as citalopram (Celexa) or escitalopram (Lexapro). SSRIs are the most commonly prescribed class of antidepressants because they are generally well-tolerated and have a low risk of side effects.

The starting dose of citalopram is 20 mg once daily. The dose can be increased to 40 mg once daily after 1 week if needed. The starting dose of escitalopram is 10 mg once daily. The dose can be increased to 20 mg once daily after 1 week if needed.

What are the monitoring parameters for a patient receiving an antidepressant?

Patients receiving an antidepressant should be monitored for the following:

Improvement in mood and depressive symptoms
Emergence of suicidal thoughts or behaviors
Side effects, such as nausea, vomiting, diarrhea, insomnia, agitation, and sexual dysfunction
Patients should be seen for follow-up 2 weeks after starting an antidepressant and then every 4-6 weeks until their mood and depressive symptoms improve. Once the patient is stable, follow-up visits can be spaced out to every 3-6 months.

At the follow-up visit the patient reports no improvement in symptoms and states she stopped taking the citalopram (Celexa) because it wasn’t working. What additional information does the patient need regarding the achievement of results from an SSRI?

SSRIs can take several weeks to start working, so it is important for patients to be patient and continue taking the medication even if they do not feel better immediately. Patients should be educated about the expected onset of action of SSRIs and the importance of taking the medication as prescribed.

Patients should also be informed that SSRIs can have side effects, such as nausea, vomiting, diarrhea, insomnia, agitation, and sexual dysfunction. These side effects are usually mild and go away on their own within a few weeks. However, if the side effects are severe or do not go away, the patient should contact their doctor.

The patient complains of morning nausea and vertigo while taking citalopram. What would be another pharmacotherapy treatment option?

Escitalopram (Lexapro) is another SSRI that is very similar to citalopram. Escitalopram is often well-tolerated by patients who experience side effects with citalopram.

Other pharmacotherapy treatment options for depression include:

SNRIs: SNRIs work by increasing the levels of both serotonin and norepinephrine in the brain. Examples of SNRIs include venlafaxine (Effexor) and duloxetine (Cymbalta).
Atypical antidepressants: Atypical antidepressants are a diverse group of drugs that work in different ways to improve mood. Examples of atypical antidepressants include bupropion (Wellbutrin), mirtazapine (Remeron), and trazodone (Desyrel).
The best pharmacotherapy treatment option for a patient with depression will depend on the individual patient’s response to treatment and side effects.

How soon should the patient return to the clinic after the change in medication for follow-up of drug effectiveness?

The patient should return to the clinic for a follow-up visit 2 weeks after starting escitalopram. This will give the medication enough time