pharmacology/atypical antidepressants

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Psychiatry

pharmacology

atypical antidepressants

Case History

A 62-year-old retired accountant, with a documented history of recurrent major depressive disorder, controlled asthma, and recently diagnosed moderate erectile dysfunction, attends a follow-up consultation in an outpatient general medical clinic. He reports persistent low mood, anhedonia, noticeable weight gain with increased appetite, and a lack of energy, impacting his daily activities over the past five months. He stopped a prior antidepressant, which he vaguely recalls as an SSRI, due to significant worsening of sexual function. Despite previously attempting smoking cessation without success, he expresses a strong desire to quit his 4 pack-year habit. His current lifestyle includes minimal physical activity. On examination, his BMI is 31 kg/m^2. His blood pressure is 138/86 mmHg, heart rate 78 bpm, respiratory rate 16 breaths/min, and temperature 36.9°C. Given his complex presentation, what is the most appropriate initial comprehensive management strategy for this patient, and what key adverse effects should be specifically monitored during the early phase of treatment?

Lab Parameter	Value	Reference Range
White Blood Cell Count	7.5 x 10^9/L	4.0-11.0 x 10^9/L
Hemoglobin	145 g/L	130-170 g/L
Platelets	280 x 10^9/L	150-450 x 10^9/L
Sodium	140 mmol/L	135-145 mmol/L
Potassium	4.1 mmol/L	3.5-5.0 mmol/L
Chloride	102 mmol/L	98-107 mmol/L
Bicarbonate	25 mmol/L	22-29 mmol/L
Glucose (fasting)	5.8 mmol/L	3.9-6.1 mmol/L
Thyroid Stimulating Hormone (TSH)	2.1 mIU/L	0.4-4.0 mIU/L
Total Cholesterol	5.5 mmol/L	<5.2 mmol/L
LDL Cholesterol	3.2 mmol/L	<2.6 mmol/L
HDL Cholesterol	1.1 mmol/L	>1.0 mmol/L
Triglycerides	1.8 mmol/L	<1.7 mmol/L

A ) Start amitriptyline at bedtime, initiate a high-fiber diet, and regularly monitor for orthostatic hypotension and constipation.

B ) Initiate bupropion sustained-release, recommend a comprehensive smoking cessation program, and closely monitor for elevated blood pressure and a lowered seizure threshold.

C ) Prescribe mirtazapine at night, suggest structured nutritional counseling, and monitor diligently for significant weight gain and increased sedation.

D ) Begin citalopram daily, refer for psychotherapy for depression, and observe for new onset sexual dysfunction and gastrointestinal distress.

E ) Recommend sertraline titration, enroll in a behavioral activation program, and assess for worsening erectile dysfunction and hyponatremia.

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