The Client Is A 32-Year-Old Hispanic American Male ✓ Solved

The client is a 32-year-old Hispanic American male who came

The client is a 32-year-old Hispanic American male who came to the United States in high school with his father. His mother died in Mexico when he was in school. He presents to the PMHNP's office for an initial appointment for complaints of depression. He was referred by his PCP after routine medical work-up to rule out an organic basis for his depression. He has no other health issues except occasional back pain and stiff shoulders from warehouse labor. MADRS score 51 (severe depression). He reports feeling like an outsider, was teased in high school for being "black", had few friends, diminished interest in activities, gained 15 pounds in 2 months, insomnia for 6 months worsening, and poor concentration affecting work.

Decision #1: start Zoloft 25 mg orally daily.

Answer: Which decision did you select? Why did you select this decision? Support with evidence and references. What were you hoping to achieve? Support with evidence and references. Explain any difference between expected and actual results and why.

Decision #2: At 4 weeks, patient reports 25% symptom reduction but new erectile dysfunction. Add Wellbutrin IR 150 mg in morning.

Answer: Why did you select this decision? Support with evidence and references. What were you hoping to achieve? Support with evidence and references. Explain differences between expected and actual results and why.

Decision #3: At 4 weeks, depressive symptoms decreased further and erectile dysfunction abated; patient reports jitteriness and nervousness. Change to Wellbutrin XL 150 mg daily.

Answer: Why did you select this decision? Support with evidence and references. What were you hoping to achieve? Support with evidence and references. Explain differences between expected and actual results and why.

Explain how ethical considerations might impact treatment plan and communication with clients.

Conclusion.

References: include Stahl (2013, 2014) and at least 3 additional credible sources.

Paper For Above Instructions

Introduction and Clinical Summary

This 32-year-old Hispanic American male presents with severe major depressive symptoms (MADRS = 51), chronic insomnia, weight gain, social withdrawal, and impaired concentration affecting work performance. He has a history of cultural and peer-related stressors (teasing, outsider feelings) and bereavement (maternal death). There are no major medical comorbidities aside from musculoskeletal complaints. The treatment decisions presented—initiate sertraline (Zoloft), augment with bupropion IR for SSRI-related sexual dysfunction, then convert to bupropion XL for stimulant-like side effects—reflect common, guideline-informed strategies for moderate-to-severe major depressive disorder (MDD) and SSRI adverse effects (APA, 2010; Stahl, 2013).

Decision 1 — Start sertraline 25 mg daily

Selected action: Initiate sertraline (Zoloft) 25 mg orally daily as the first pharmacologic step.

Rationale and evidence: SSRIs are first-line pharmacotherapy for MDD because of demonstrated efficacy, tolerability, and safety compared with older agents (APA, 2010; NICE, 2009). Sertraline has strong evidence for efficacy in adult MDD and a generally favorable side-effect profile (Stahl, 2014). Starting at 25 mg (below the common 50 mg starting dose) can be appropriate in patients with anxiety, sleep disturbance, or sensitivity to activation, or when a clinician wishes to minimize early side effects and improve adherence (Stahl, 2013). Given the patient’s insomnia and anxiety-like features, a lower initial dose with close follow-up is reasonable to reduce early activation or worsened insomnia (Stahl, 2013).

Treatment goals: Reduce depressive symptom severity (target MADRS reduction ≥50% within 6–8 weeks), improve sleep and concentration, restore functioning, and reduce suicide risk. The expected timeline is partial improvement by 2–4 weeks and a more robust response by 6–8 weeks (APA, 2010).

Expected vs. actual outcomes: A 25% reduction in symptoms at 4 weeks (as the case later reports) represents a partial response and aligns with expected early improvement patterns for SSRIs (Stahl, 2013). Differences from ideal full remission by 4 weeks are typical—most patients require dose optimization and up to 6–8 weeks for maximal effect.

Decision 2 — Add bupropion IR 150 mg AM for SSRI-induced erectile dysfunction

Selected action: Augment sertraline with bupropion immediate release (IR) 150 mg in the morning after sexual dysfunction emerged.

Rationale and evidence: Sexual dysfunction is a common adverse effect of SSRIs that can impair adherence (Montejo et al., 2001; Clayton, 2010). Bupropion, a norepinephrine–dopamine reuptake inhibitor (NDRI), is associated with lower rates of sexual dysfunction and has been used both as monotherapy and as augmentation to mitigate SSRI-induced sexual side effects and to boost antidepressant response (Stahl, 2014; Papakostas, 2009). Evidence supports bupropion augmentation as a reasonable strategy when sexual dysfunction emerges from SSRI therapy (APA, 2010; Fava et al., 2006).

Treatment goals: Reverse or reduce sexual side effects (improve erectile function) while maintaining or improving antidepressant response. Bupropion’s dopaminergic activity helps restore libido and erectile function for some patients (Montejo et al., 2001).

Expected vs. actual outcomes: The vignette reports that erectile dysfunction abated and depressive symptoms improved further, consistent with expected benefits of bupropion augmentation. Anticipated risks include increased anxiety, insomnia, or jitteriness and a small risk of seizures (dose-dependent) (FDA bupropion label; Stahl, 2014). These risks require monitoring and patient counseling.

Decision 3 — Change to bupropion XL 150 mg daily because of jitteriness

Selected action: Convert bupropion IR to bupropion XL 150 mg once daily to address stimulant-like adverse effects (jitteriness, nervousness).

Rationale and evidence: IR bupropion produces peak plasma concentrations that can be associated with greater stimulant effects. The XL formulation provides smoother pharmacokinetics with lower peak-to-trough fluctuation, often reducing activation-related adverse effects while maintaining efficacy (FDA bupropion label; Stahl, 2014). Converting to XL can improve tolerability and adherence while preserving the desired antidepressant and pro-sexual effects.

Treatment goals: Reduce jitteriness and nervousness while maintaining remission/response of depressive symptoms and preserving sexual function gains. Monitor for ongoing anxiety, insomnia, or emergent adverse effects and reassess dosing.

Expected vs. actual outcomes: If symptoms of jitteriness abate after the change, this matches pharmacokinetic expectations. If jitteriness persists, consider dose reduction, timing adjustments (take earlier in morning), behavioral strategies, or alternative augmentation strategies.

Ethical and cultural considerations

Ethical practice demands informed consent, culturally sensitive communication, and shared decision-making. This patient’s Hispanic background, bereavement history, and reported social isolation require assessment of cultural beliefs about mental illness, stigma, language needs, and family involvement in treatment decisions (APA, 2010). Confidential discussion of sexual side effects and occupational implications is essential to respect autonomy and support adherence. Clinicians must screen for suicidality given severe depression (MADRS 51) and document safety planning and follow-up. Equity and access issues (cost of medications, work schedule) should inform medication choices. Finally, clinicians must avoid coercion, ensure confidentiality, and appropriately involve interpreters or family per patient preference.

Conclusion

This stepped approach—initiation of an SSRI, thoughtful management of SSRI-induced sexual dysfunction with bupropion augmentation, and optimization of formulation to improve tolerability—aligns with guidelines and pharmacologic rationale (APA, 2010; Stahl, 2013, 2014). Each decision balances efficacy, tolerability, and patient-centered factors. Continuous monitoring for response, side effects, suicidality, and adherence, along with culturally competent communication and shared decision-making, are essential to achieve remission and functional recovery.

References

• Stahl, S. M. (2013). Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications (4th ed.). Cambridge University Press.
• Stahl, S. M. (2014). The Prescriber's Guide: Antidepressants and Other Psychotropic Medications (5th ed.). Cambridge University Press.
• American Psychiatric Association. (2010). Practice Guideline for the Treatment of Patients with Major Depressive Disorder. American Psychiatric Association.
• National Institute for Health and Care Excellence (NICE). (2009). Depression: The treatment and management of depression in adults (Clinical guideline CG90).
• National Institute of Mental Health. (2020). Depression. https://www.nimh.nih.gov/health/topics/depression
• U.S. Food and Drug Administration. Sertraline (Zoloft) Prescribing Information. Available at FDA website.
• U.S. Food and Drug Administration. Bupropion (Wellbutrin) Prescribing Information. Available at FDA website.
• Montejo, A. L., Llorca, G., Izquierdo, J. A., & Rico-Villademoros, F. (2001). Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients. Journal of Clinical Psychiatry, 62(Suppl 3), 10–21.
• Clayton, A. H. (2010). Antidepressant-associated sexual dysfunction: evaluation and treatment. Primary Care Companion to the Journal of Clinical Psychiatry, 12(1).
• Papakostas, G. I. (2009). Pharmacologic approaches to treatment-resistant depression. Psychiatr Clin North Am, 32(2), 299–310.