2 pages Examine Case Study: An Elderly Hispanic Man With Major Depressive Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the clients pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following: 

Decision #1 

Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

Decision #2 

Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. 
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

Decision #3 

Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients.

BACKGROUND INFORMATION
The client is a 32-year-old Hispanic American male who came to the United States when he was in high school with his father. His mother died back in Mexico when he was in school. He presents today to the PMHNPs office for an initial appointment for complaints of depression. The client was referred by his PCP after routine medical work-up to rule out an organic basis for his depression. He has no other health issues with the exception of some occasional back pain and stiff shoulders which he attributes to his current work as a laborer in a warehouse. 
SUBJECTIVE
During todays clinical interview, client reports that he always felt like an outsider as he was teased a lot for being black in high school. States that he had few friends, and basically kept to himself. He describes his home life as good. Stating Dad did what he could for us, there were 8 of us. He also reports a remarkably diminished interest in engaging in usual activities, states that he has gained 15 pounds in the last 2 months. He is also troubled with insomnia which began about 6 months ago, but have been progressively getting worse. He does report poor concentration which he reports is getting in trouble at work. 
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is casually dressed. Speech is clear, but soft. He does not readily make eye contact, but when he does, it is only for a few moments. He is endorsing feelings of depression. Affect is somewhat constricted, but improves as the clinical interview progresses. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment and insight appear grossly intact. He is currently denying suicidal or homicidal ideation. The PMHNP administers the Montgomery- Asberg Depression Rating Scale (MADRS) and obtained a score of 51 (indicating severe depression).
RESOURCES
§ Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.
Decision Point One
Select what the PMHNP should do:
Begin zoloft 25 mg orally daily
Begin Effexor XR 37.5 mg orally daily
Begin Phenelzine 15 mg orally TID
Decision Point One

Begin zoloft 25 mg orally daily
RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Reports a 25% decrease in symptoms
Client is concerned over the new onset of erectile dysfunction

Decision Point Two
Select what the PMHNP should do next:
Decrease dose to 12.5 mg orally daily 
Continue same dose and counsel client
Add augmenting agent such as Wellbutrin IR 150 mg in morning

Decision Point Two

Add augmenting agent such as Wellbutrin IR 150 mg in morning
RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client stated that depressive symptoms have decreased even more and his erectile dysfunction has abated
Client reports that he has been feeling jittery and sometimes nervous 

Decision Point Three
Select what the PMHNP should do next:
Discontinue Zoloft altogether and continue with Wellbutrin 
Change Wellbutrin to XL 150 mg orally daily in AM
Add Ativan 0.5 mg orally TID/PRN for anxiety
Decision Point Three

Change Wellbutrin to XL 150 mg orally daily in AM
Guidance to Student
The PMHNP should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the clients complaint of jitteriness is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as the PMHNP should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect.