Amina Zaminetti is a 45-year-old woman with sleep apnea, hypertension, type 2 diabetes, and chronic pain. She is being seen in the clinic today for a medication evaluation and an assessment of her depressive symptoms. She endorses a sad mood, poor appetite (lost 15 lb.), poor concentration, and feelings of hopelessness and worthlessness for the past three weeks. She has also stopped going to her book club because she is not motivated to get out of the house, and she has frequent nocturnal awakening. Amina denies suicidal or homicidal ideation. She denies any use of alcohol, tobacco, or illicit drugs. She is currently taking hydrochlorothiazide, metformin, hydrocodone/acetaminophen, and aspirin. Her current BMI is 20 kg/m2, and her blood pressure today is 152/94 mm Hg. She reports adherence to her current medications.
After carefully reading the scenario, respond to the following four parts:
Part A: Which of the following antidepressants would be appropriate for Aminaâ€™s depressive symptoms: Bupropion, fluoxetine, mirtazapine, venlafaxine, or citalopram? Please explain your choice and why the others are not ideal.
Part B: It has been four weeks since Aminaâ€™s initial visit with you and she has been taking citalopram 20 mg/day in the morning. She still presents with sad mood and has feelings of hopelessness and worthlessness. She also reports a lack of motivation and anhedonia. However her insomnia, concentration, and appetite have improved. At this point, which is the best recommendation to optimize her therapy? Explain your choice and why the other options were not selected.
Part C: Six months later, Amina reports that although her depression symptoms have resolved, she has trouble during intercourse, which is quite disturbing to her. You determine she has anorgasmia caused by citalopram treatment. Which is the most appropriate recommendation at this time? Explain your answer.
Part D: At the same six-month appointment Amina reports she has an increase in her migraines. While this is a new complaint in your interactions with her, she has a distant history in her medical records of migraines that were successfully treated with triptan abortive therapy. What would be a reasonable drug therapy for this condition for you to recommend? Please explain your answer and include the full regimen you would provide (and how you would educate the patient on how to utilize the treatment correctly).
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