July 11, 2026 — Transcript

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1. 0:00Good afternoon, everyone.
2. 0:01My name is Melinda Nelson, and today I
3. 0:03will be discussing the pharmacological
4. 0:05treatment of major depressive disorder
5. 0:07in a 18-year-old female.
6. 0:09I will review the first and second-line
7. 0:11medication options, mechanisms of
8. 0:12action, pharmacokinetics, and
9. 0:15pharmacodynamics.
10. 0:17Prescription writing, adverse effects,
11. 0:19monitoring, and non-pharmacological
12. 0:21treatment, and patient education.
13. 0:28For first-line treatment, I selected
14. 0:29sertraline, also known as Zoloft.
15. 0:32Sertraline is a selective serotonin
16. 0:33reuptake inhibitor, also known as SSRI,
17. 0:37and SSRIs are commonly used as initial
18. 0:39treatment for major depressive disorder
19. 0:41because they are effective and generally
20. 0:43better tolerated than older
21. 0:44antidepressants.
22. 0:46Sertraline is appropriate for Sarah
23. 0:48because she is experiencing depressive
24. 0:49symptoms along with increased stress and
25. 0:51sleep disturbances associated with
26. 0:53starting college.
27. 1:02Mechanisms of action. Sertraline works
28. 1:04by selectively inhibiting the serotonin
29. 1:06transporters
30. 1:08on the presynaptic neuron.
31. 1:10By blocking serotonin reuptake, more
32. 1:12serotonin remains available in the
33. 1:14synaptic cleft.
34. 1:16Over time, increased serotonergic
35. 1:19neurotransmission and neuro adaptive
36. 1:20changes help improve mood and often
37. 1:22symptoms of depression.
38. 1:24This also explains why patients do not
39. 1:26usually experience the full therapeutic
40. 1:28benefit immediately.
41. 1:37Pharmacokinetics.
42. 1:39Looking at the pharmacokinetics,
43. 1:40sertraline is well absorbed orally and
44. 1:42has a bioavailability of approximately
45. 1:4544%.
46. 1:46Peak concentrations occur within about 4
47. 1:48and 4 and 1/2 to 8 hours.
48. 1:52It is highly protein bound and undergoes
49. 1:54hepatic metabolism through several
50. 1:57CYP2D6
51. 1:58enzymes. Sertraline has a half-life of
52. 2:01approximately 26 hours, which supports
53. 2:03one daily dose.
54. 2:06Its inactive metabolites are eliminated
55. 2:08through the urine and feces.
56. 2:12>> [snorts]
57. 2:16>> Pharmacodynamics.
58. 2:19Pharmacodynamically, sertraline
59. 2:20increases serotonergic neurotransmission
60. 2:23by inhibiting serotonin reuptake.
61. 2:26Clinically, this can lead to improvement
62. 2:28in mood, anhedonia, energy,
63. 2:31concentration, and anxiety symptoms. It
64. 2:34is important to educate the patient that
65. 2:36improvement may begin within two to four
66. 2:38weeks, but the maximum therapeutic
67. 2:39response can take six to eight weeks.
68. 2:47The second line of pharmacological
69. 2:48treatment, um I selected bupropion
70. 2:52XL, also known as Wellbutrin XL.
71. 2:56Wellbutrin is a norepinephrine
72. 2:59dopamine reuptake inhibitor.
73. 3:03It increases norepinephrine and dopamine
74. 3:05activity and has a minimal serotonergic
75. 3:08activity. This can improve energy,
76. 3:11motivation, fatigue, and concentration.
77. 3:14One advantage is that Wellbutrin
78. 3:16generally has less sexual dysfunction
79. 3:18and weight gain compared to SSRIs.
80. 3:21However, it lowers the seizure threshold
81. 3:23and should be avoided in patients with
82. 3:25seizure disorders or eating disorders.
83. 3:30For the prescription for this patient, I
84. 3:32would prescribe sertraline 50 mg.
85. 3:35The prescription would read sertraline
86. 3:3750 mg tablets, dispense
87. 3:4030 tablets. The patient should take one
88. 3:42tablet by mouth once daily, and I would
89. 3:44also provide two refills and allow
90. 3:47generic substitution.
91. 3:49This provides all of the major elements
92. 3:51necessary for the pharmacy to accurately
93. 3:53fill the prescription.
94. 4:00Drug and food interactions. Important
95. 4:03drug and food interactions include
96. 4:05MAO inhibitors, other serotonergic
97. 4:09medications such as St. John's Wort,
98. 4:11Tramadol, and lithium. Combining
99. 4:14multiple medications can increase the
100. 4:15risk of serotonin syndrome. Alcohol
101. 4:18should be minimized because it may
102. 4:19worsen depression symptoms and increase
103. 4:22central nervous system adverse effects.
104. 4:24Additionally, NSAIDs may increase the
105. 4:26risk of bleeding when combined with
106. 4:28SSRIs.
107. 4:32Adverse effects.
108. 4:34Some common adverse effects of
109. 4:35sertraline include nausea, diarrhea,
110. 4:37insomnia, headache, dry mouth, and
111. 4:39fatigue. Patients may also experience
112. 4:41sexual dysfunction, weight changes, or
113. 4:43hyponatremia.
114. 4:44Some serious adverse effects include
115. 4:46serotonin syndrome, abnormal bleeding,
116. 4:48and increased suicidal thinking in
117. 4:49younger patients.
118. 4:51Because Sarah is 18 years old, we want
119. 4:53to monitor her for worsening depression
120. 4:55or suicidal state thoughts.
121. 4:57Um especially which is important after
122. 5:00initiating the treatment.
123. 5:06So, for monitoring. Monitoring should
124. 5:07include the PHQ-9 to assess depressive
125. 5:10symptoms and the Columbia Suicide
126. 5:12Severity Rating Scale when evaluating
127. 5:14suicide risk. I would also monitor
128. 5:15medication adherence, sleep, appetite,
129. 5:18weight, and signs of serotonin syndrome.
130. 5:20Sodium levels can also be assessed if
131. 5:22there are clinical concerns of
132. 5:23hyponatremia.
133. 5:25Routine laboratory monitoring is not
134. 5:27generally required in otherwise healthy
135. 5:29patients taking sertraline. However,
136. 5:31close clinical follow-up is important. I
137. 5:33will follow up within 1 to 2 weeks after
138. 5:35initiation and reassess treatment
139. 5:37response again 4 to 6 weeks.
140. 5:43Non-pharmacological treatment.
141. 5:46Medication should be combined with
142. 5:47evidence-based non-pharmacological
143. 5:49interventions.
144. 5:51Cognitive behavioral therapy, also known
145. 5:53as CBT, and interpersonal therapy are
146. 5:56effective treatment options for
147. 5:57depression.
148. 5:58Behavioral activation can also help
149. 6:00Sarah gradually increase her
150. 6:02participation in a
151. 6:04meaningful and enjoyable activities.
152. 6:07Regular exercise, sleep hygiene, and
153. 6:09stress management strategies should be
154. 6:12encouraged.
155. 6:13Since Sarah is transitioning into
156. 6:14college, campus counseling services and
157. 6:17strong social support may also be
158. 6:19beneficial.
159. 6:25Patient education is extremely important
160. 6:27when initiating sertraline.
161. 6:29I would explain to Sarah that the
162. 6:31medication may take several weeks to
163. 6:32produce noticeable improvement and that
164. 6:34she should take it consistently every
165. 6:35day. She should not abruptly discontinue
166. 6:38the medication without speaking to her
167. 6:39provider.
168. 6:40I would advise her to minimize alcohol
169. 6:43and avoid recreational drugs. She should
170. 6:45immediately report worsening depression
171. 6:47or suicidal thoughts.
172. 6:49Sarah should also avoid St. John's Wort
173. 6:52unless approved by her provider and
174. 6:54discuss any new medications or
175. 6:55supplements being started.
176. 6:57Finally, I would recommend and encourage
177. 6:59her to continue counseling even if her
178. 7:02symptoms begin to improve.