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Sylvia is a 60-year-old female who presents to the PMHNP with chief complaint of “feeling down”.  She has been taking citalopram 40mg daily for the past two years from her PCP but feels she has not gotten any better.  She endorses depressed mood and anhedonia.  She has trouble falling asleep, has been overeating, and has gained about 15 lbs in the past year.  She worked as a waitress for over 40 years but left her job about three years ago after her husband had a stroke because she needed to care for him.  She shares that he has had a full recovery and no longer needs her assistance, but that she never returned to work and barely leaves the house.  She denies thoughts of harming herself or anyone else, but does endorse low self-esteem and is particularly focused on her recent weight gain. 

What treatment recommendations would you have for Sylvia?  

In terms of medication, what would your plan be?  Be specific in terms of any changes you might make.

Name one medication that you would avoid using in Sylvia and why.

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