A 43-year-old man comes to the office due to depression. He feels sad and unmotivated, sleeps 12 hours a day, and has increased appetite, poor concentration at work, and fleeting thoughts of suicide. The patient has no medical history and laboratory evaluation is unremarkable. Major depressive disorder is diagnosed and antidepressant medication administered. Several weeks after starting the medication, the patient's depressive symptoms are mildly improved, but he is now distressed by a significant decrease in libido and impaired sexual performance. He is considering stopping the medication and requests an alternate treatment. Which of the following drugs is most appropriate for this patient?

Question

A 43-year-old man comes to the office due to depression.  He feels sad and unmotivated, sleeps 12 hours a day, and has increased appetite, poor concentration at work, and fleeting thoughts of suicide.  The patient has no medical history and laboratory evaluation is unremarkable.  Major depressive disorder is diagnosed and antidepressant medication administered.  Several weeks after starting the medication, the patient's depressive symptoms are mildly improved, but he is now distressed by a significant decrease in libido and impaired sexual performance.  He is considering stopping the medication and requests an alternate treatment.  Which of the following drugs is most appropriate for this patient?

Quizplus · Accepted Answer

This patient was most likely treated with a selective serotonin reuptake inhibitor (SSRI), a commonly prescribed initial treatment for major depressive disorder that causes sexual dysfunction in up to 50% of patients. SSRI-related sexual side effects include decreased libido, decreased arousal, anorgasmia, and increased ejaculation latency. Bupropion is an antidepressant that does not cause sexual dysfunction. It is classified as a norepinephrine-dopamine reuptake inhibitor. Because of its stimulating effects, bupropion is useful in treating depression associated with hypersomnia and low energy. Bupropion is also preferred because it causes less weight gain compared with other antidepressants. Bupropion is contraindicated in patients with bulimia nervosa, anorexia nervosa, and seizure disorders because it lowers the seizure threshold. (Choices B and D) Citalopram and sertraline are SSRIs that would likely cause sexual dysfunction in this patient. Switching to a non-SSRI such as bupropion is more likely to improve his sexual dysfunction. (Choice C) Imipramine is a tricyclic antidepressant with numerous side effects, including sexual dysfunction. These types of antidepressants are dangerous in overdose because of cardiotoxicity, so they are not a first-line treatment for depression. (Choice E) Trazodone is a highly sedating antidepressant that can be helpful for patients with insomnia. Trazodone can cause sexual dysfunction and priapism, a rare but serious side effect. (Choice F) Venlafaxine is a serotonin-norepinephrine reuptake inhibitor that can cause sexual side effects. Educational objective: Sexual dysfunction is seen in up to 50% of patients treated with selective serotonin reuptake inhibitors. Bupropion, a norepinephrine-dopamine reuptake inhibitor, is a first-line treatment for major depressive disorder and does not cause sexual dysfunction. __________ References: Bupropion in the depression-related sexual dysfunction: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/24923342) Bupropion. (http://www.ncbi.nlm.nih.gov/pubmed/29262173)

A 43-Year-Old Man Comes to the Office Due to Depression