Clinical History

Justin is a 22-year-old Hispanic male who works full-time in an auto parts warehouse and attends community college part-time in the evening. He recently sought counseling for depression at the urging of his new girlfriend. He claims that he has always had a problem with depression, even as a youngster, but attributed it to the chaotic household he grew up in. His parents divorced when he was very young due in part to his dad's heavy drinking. Justin claims he does not remember his father very much. His mother told him his father moved back to Guatemala when Justin was just three years old. Justin has one older sister, who is a nurse. While she often looks and acts as if she is depressed, she claims she is not, nor has she sought treatment of any kind. Justin's mother, however, has been placed on antidepressants by her PCP at various times.

Justin admits that he used alcohol in his teen years to self-medicate his depression. His alcohol use became problematic in the last two years, and this led to a breakup with his fiance Marta four months ago. He decided shortly after that to refrain from using alcohol when he met his current girlfriend, Elena, at a work-related event. He has noticed that his depressive symptoms worsened when he didn't have something to "soothe it." He is most bothered by poor sleeping and difficulty concentrating at work. While he is very happy about meeting Elena, his depression has escalated recently, leading to thoughts of suicide on at least two occasions.

Postcase Discussion and Diagnosis

Justin is suffering with Major Depressive Disorder that appears to be rather Chronic and Severe in nature (F33.2). He reports problems with poor sleepingnamely, terminal insomnia. He further presents with concentration concerns, feelings of sadness, and suicidal ideation. There also appears to be positive family history for mood disorders. Although he reports past issues with alcohol, there appears to be no reason for detox at this time. Since gaining sobriety, he has noticed an increase in depressive symptoms, indicating a need to treat depression as a causal factor for his drinking. A complete physical was conducted with his PCP and all blood work and other findings were within normal limits.

Psychopharmacological Treatment

Justin was started on a conservative starting dose of 5 mg daily of Lexapro by his family doctor. He was watched closely by his physician and therapist for any signs of mood changes or an increase in suicidal thinking. Within two weeks he reported an improvement in both mood and outlook. Elena also noticed a big change, but Justin reported that his early morning awakening, although better, has not fully improved. His dose was increased to 10 mg daily. Within a month, he reported that he was able to sleep through the night without awakening. At one visit with his therapist, Justin complained that although he was happy with his overall level of improvement, he had noticed that it was much more difficult to have an orgasm when he was with Elena. Upon consultation with his doctor, a low dose of bupropion was added each day. Three weeks later, Justin reported that he was doing well, with no problems "in the sex department."

Questions

1.In addition to the diagnosis suggested by the text authors, are there additional disorders that may apply or should be ruled-out? 2.Do you agree with the medication suggestions made by the text authors? 3.Any other medications that might be considered...and what is the rationale? 4. Are the suggested medications, or any other considered medications, agonists or antagonists? 5.If you were asked to follow-up on this case as the treating therapist, what would your treatment plan be? Include collaboration and consultation.