Depressive Symptoms in Primary Care: Patient-guided Medication Choices

00:01 Hello again.

00:03 This is Kimberly Oman.

00:04 I'm a nurse practitioner.

00:06 Today we're going to revisit the case of Mrs.

00:08 Jessica Jones, who presented to the primary care setting with depressive symptoms.

00:14 She has completed a PHQ-9 with a score of 14, which is indicative of moderate depression. The patient has indicated she wants to try medication, and she is here for an appointment to discuss her options.

00:29 In this video, we are going to be talking about initiating medication treatment for her depressive symptoms.

00:36 To review, Jessica is meeting basic daily needs for herself and her family, although considerably lacking in motivation.

00:45 Medical history is significant for anemia during pregnancy.

00:50 She had labs done within the past year, which were normal, and her medical history otherwise seems uncomplicated.

00:59 She has no past psychiatric history.

01:03 Her family history is significant, that her sister has anxiety and depression, and we believe her sister is taking medication, but her sister's current medication is unknown.

01:16 You mentioned that your sister has a history of anxiety and depression.

01:20 Do you know what she might be taking and if it's been helpful for her? I think, I think it was called Zoloft.

01:30 Yes, Zoloft.

01:32 Okay. Oftentimes I ask because if one family member is doing well with a certain medication, a lot of times another family member might be doing well, too.

01:42 I just remember her saying it made her feel zoned out, and I don't want to feel that way.

01:49 Okay.

01:51 When considering medication for a patient who is treatment naive, it can be helpful to ask them if a relative is doing well with a particular medication.

02:01 It is important to clarify whether the patient's family member is a blood relative and share some of the same genes.

02:09 Knowing what medication a step sibling is taking is not helpful, and you'd be surprised how many patients will start telling you about their step siblings.

02:19 So we definitely need to clarify.

02:23 Also, if her sister's medication isn't working, then maybe we need to try a different medication.

02:30 You mentioned that you haven't had any recent labs checked, right? And you mentioned having anemia in the past, which can contribute to feeling fatigued.

02:41 It may be worth it to check some more recent labs.

02:45 Uh, do we have to do that before we start anything? I think we could go ahead with starting medication today, just based on the history that you've given me.

02:55 But ordering some labs at some point is not a bad idea.

02:58 Okay.

03:00 Use your clinical judgment if you believe that a medical cause needs to be ruled out before initiating medication, do it.

03:09 You are the provider.

03:11 Reassure the patient you are making your decision with their best interests at heart, and patient safety is paramount.

03:20 Jessica has clearly verbalized that she is not suicidal or homicidal.

03:25 She is not considered a safety risk to herself or others.

03:29 If there was a safety risk concern, it would require immediate intervention and evaluation for inpatient hospitalization for psychiatric stabilization.

03:41 Since these concerns are not present in this case, Jessica is considered stable for outpatient treatment. Jessica meets the diagnostic criteria for recurrent moderate major depressive episode according to the DSM V.

03:58 Jessica's major depressive episode is considered uncomplicated.

04:03 She has denied a past psychiatric history or prior treatment, so she is not treatment resistant that we are aware of. Jessica has not reported or displayed any symptoms consistent with mania. There is no evidence of psychosis.

04:20 Jessica has had a tubal ligation and it is extremely unlikely that she is pregnant.

04:26 There are no acute safety concerns.

04:30 Clinically, it is logical to treat Jessica appropriately based on her history and her current presentation. Jessica, you said you weren't interested in going to therapy.

04:42 Okay. But if that changes at all, let me know.

04:45 I really think that therapy in combination with medication would be really helpful.

04:50 Okay, thanks.

04:52 Okay.

04:53 Alright. If your sister has been feeling zoned out with Zoloft, I think we could probably try to do something different. So, just for example, fluoxetine, which people know is Prozac.

05:06 All right. It's in the same drug class as Zoloft.

05:09 And it works similarly on the brain to increase serotonin levels.

05:13 Okay, um, can you tell me some more about that? This is the time now to educate, educate, educate.

05:22 For example, fluoxetine might make a patient feel sleepy or nauseous.

05:28 And both of these symptoms may resolve after a few weeks if the patient is sleepy.

05:34 We could try changing the timing of the dose to bedtime.

05:39 We need to discuss what Jessica should do if she begins having serious suicidal thoughts once she starts taking medication and we need to let Jessica know what she might expect as far as when she will start benefiting from the medication.

05:54 Patient education will improve medication compliance and outcomes to treatment.

06:01 So let's fast forward six weeks and see Jessica again in the clinic for follow up to reevaluate her depression symptoms.

06:10 Hey, Jessica.

06:12 Hey.

06:12 Hi. You've been on fluoxetine now for about six weeks.

06:17 How are you doing? Uh, well, I was feeling pretty sleepy when I started, but I think that's getting better.

06:25 I was a little sick to my stomach, but I think that's gone away as well.

06:29 Um. And I'm so glad you warned me about that.

06:33 I would have stopped if I didn't know what to expect.

06:36 Good, good. I'm glad you kept taking it.

06:41 Alright. How's your mood doing? Has your family noticed any changes? Or have there been any suicidal thoughts? No. No suicidal thoughts.

06:52 I think I'm feeling more positive and my husband says that I'm smiling more.

06:58 I feel a little better about getting up in the morning and getting stuff done.

07:03 I still really don't want to have sex.

07:05 I mean, I feel like things could be better, but maybe that's unrealistic.

07:12 Okay, so it sounds like overall, generally things are going a little bit better.

07:18 Yeah a little bit.

07:19 Yeah.

07:20 Okay. I know sex is really, really important in a relationship.

07:25 Okay.

07:25 Um, my husband would like it to be, but, um.

07:30 So with relationship to how the medication affects sex, there's a few different things that we could consider.

07:37 Okay. Sometimes sex drive will continue to get a little bit better the longer you've been taking the medication.

07:45 Okay.

07:46 It's possible that the medication can dampen your sex drive a little bit.

07:52 We just don't know until you take it for a little bit longer.

07:56 Okay.

07:58 But if it's been a few more weeks or a few more months and your sex drive is still not any better, we're at a point where we can consider adding another medication that might help with that.

08:09 So it's one of those things where we might need to cross that bridge when we get there.

08:14 Okay.

08:16 There's a medication that I like to use.

08:18 It's called bupropion.

08:21 Okay. And it can actually help a lot with motivation, with energy level and with sex drive.

08:29 Okay. So we don't need to start anything new now.

08:33 We just just something to think about in the future.

08:36 Okay. That'll be good to talk about when I come back.

08:40 And when can I come back? We could probably do about another 6 to 8 weeks.

08:46 Okay. Okay. And if you're having any trouble before that, you just call and let me know.

08:50 Okay. Okay.

08:51 Okay, I'll think about that.

08:53 Thanks. Okay.

08:56 When I was a nurse practitioner student, no one told me how comfortable I would need to be asking about sex during a patient appointment.

09:06 Never underestimate how important sex is in a relationship and relate and in relation to making medication decisions, you need to develop a reasonable level of confidence asking some not always so comfortable questions.

09:21 The more you ask these questions, the more comfortable you will be.

09:26 Jessica voices feeling better overall, but there is room for improvement. Because Jessica is feeling more positive, you will have to follow her cues on what she is comfortable with for your next clinical choices.

09:43 The initial diagnosis of major depressive disorder continues to be appropriate.

09:49 There has not been any evidence of mania or psychosis, either at our initial or follow-up visits, and there is no evidence of suicidality.

10:01 At this time, treatment and management of Jessica will involve continued follow-up and reassessment.