33 year old white, gay, cisgender male who presented with history of depression; he is seeking care to address negative, rumantive cycle of thoughts. He began with our virtual practice 8/2021. He comes from a strong Christian background and had marked difficulty during adolescence with his gender identification and sexual orientation. He was in college when he first noticed being depressed. At the time he was seeing a university-based provider who it started him on an unknown antidepressant which he took for three months. At no time had he endorsed suicidal ideation but stopped taking the medication when school ended. Since that time he has not proceeded with further evaluation nor treatment.
In August, he begin to use our virtual service for primary care and subsequently behavioral health counseling with our team psychologist. Of note the patient has not had ability to maintain an erection as far as he can remember back to adolescence. I had ordered a thyroid function, serum testosterone and routine bloodwork for which he has not gotten done yet. His BMI is 35 and when we moved through his informed decision regarding medications for depression he agreed to take bupropion based on his lower incidence of waking and sexual dysfunction. I had started him on 150 mg PO daily there’s some improvement noted. He had side effects soon after increasing to 300 mg daily. He’s self discontinued the medication and when I reached out we again discussed needing medication and we decided to start a citalopram 10 mg per day. Two weeks later, upon follow up, he states he did not start the medication as he was concerned about potential side effects such as weight gain and sexual dysfunction. PHQ-9 at 12 and GAD-7 10.
- I chose NDRI class bupropion SR 150 mg po daily based on his weight and concern for sexual dysfunction. When increased to 300 mg, he experienced nausea, feeling dizzy and lightheaded. How should I approach dosing adjustments?
- I explained that escitalopram has limited side effects but is an SSRI and each patient may have an individual response. I let him know this is an isomeric form of citalopram and should have minimal side effects, but he has not yet started this. How can I counsel him?