What medication would you first prescribe to this patient?
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First, I would prescribe citalopram, an antidepressant drug of the SSRI (selective serotonin reuptake) class since the patient needs to improve her mood and attitude to life. In fact, any medication belonging to this class will suit to treat her condition since all of them create a feeling of well-being and increase the patient’s energy levels by restoring the amount of serotonin in the brain. Furthermore, this medication typically ranges among 10-20 antidepressants for its cost-effectiveness and positive effect on patients being even more effective than reboxetine and paroxetine (Beach et al., 2014). Since the patient does not report any other symptoms going beyond depression, this will be enough for the first visit.
She comes back in 2 weeks and states she has not noticed and change in her mood since starting on the medication. What would be your response?
If the patient comes back in two weeks and states that her mood has not changed, I would explain to her that it usually takes no less than 4-6 weeks for such medications to work. I would also ask the patient whether she could report any side effects and whether she stopped taking the medication thinking that it did not work. The point is that citalopram is capable of producing serious withdrawal effects, which makes it dangerous to discontinue the treatment without consulting a specialist. Moreover, I would try to explain to the patient that the medication was prescribed to her since her doctor believed that its benefit was greater than the risk of having any side effects or having no positive effect at all.
What are the possible problems with the medication you prescribed?
Citalopram may cause a number of side effects, which are typically rare (however, in some cases, patients may require medical attention). They include confusion, anxiety, loss of memory, fever, blurred vision, lack of emotion, increase in the frequency of urination, menstrual changes, trouble breathing, bleeding, liver disease, heart disease or irregular heartbeat, bleeding gums, behavior changes (similar to those occurring to a drunk person), breast enlargement, tenderness, or milk secretion, seizures, chills, inability to concentrate, poor coordination, diarrhea, dizziness, increased thirst and hunger, fainting, overactive reflexes, lethargy, red spots all over the skin, irritated eyes, peeling of the skin, welling of the face and hands, rapid weight gain, shivering, sore throat, excessive sweating, uncontrolled excitement, trembling, unusual body and face movements, weakness, fatigue, etc. (Mamdani, Berlim, Beaulieu, & Turecki, 2014).
The majority of effects that most frequently occur to patients do not need any medical intervention since they go away in the course of the treatment, as soon as the body completely adjusts to the drug. They are mild and transient, observed in the first two weeks of the treatment, which implies that for most patients they are likely to go unnoticed. The most commonly reported consequences include dry mouth, tremor, nausea, increased sweating, diarrhea, urination disorder, hypotension, decreased or increased weight, loss of appetite, and chest pain (Lavretsky et al., 2015). However, it is important to note that some of the symptoms are still unknown, which makes it crucial to warn the patient that she must report any unpleasant feelings she has while taking it.
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How long should you continue the treatment regimen?
The length of the regimen is individual and depends entirely on the patient’s reaction to the medication. In the majority of cases, appetite, energy, and sleep improve considerably within the first two weeks. Any improvements in the patient’s condition show that the medication is working properly. Yet, more serious symptoms (such as the lack of interest in life, frustration, and depressed mood) may need up to 8 weeks to disappear (Lavretsky et al., 2015). If it does not happen, the patient needs other drugs to couple with citalopram.
Beach, S. R., Kostis, W. J., Celano, C. M., Januzzi, J. L., Ruskin, J. N., Noseworthy, P. A., & Huffman, J. C. (2014). Meta-analysis of selective serotonin reuptake inhibitor-associated QTc prolongation. The Journal of Clinical Psychiatry, 75(5), 441-449.
Lavretsky, H., Reinlieb, M., St. Cyr, N., Siddarth, P., Ercoli, L. M., & Senturk, D. (2015). Citalopram, methylphenidate, or their combination in geriatric depression: A randomized, double-blind, placebo-controlled trial. American Journal of Psychiatry, 172(6), 561-569.
Mamdani, F., Berlim, M. T., Beaulieu, M. M., & Turecki, G. (2014). Pharmacogenomic predictors of citalopram treatment outcome in major depressive disorder. The World Journal of Biological Psychiatry, 15(2), 135-144.