A 45-year-old woman returns to the office for follow-up of depression. Three months ago, she was diagnosed with major depressive disorder with suicidal ideation and was started on sertraline. At her one-month follow-up, the patient had slight improvement with no suicidal ideation but reported sexual dysfunction with anorgasmia. She has been in a mutually supportive relationship with a single partner for several years and had not experienced sexual dysfunction previously. Her sertraline dose was decreased to help with this effect. At today's visit the patient reports that her mood is "okay" but that she still has "more down days than not" and low energy. She continues to suffer from anorgasmia, which is distressing and negatively affecting her relationship.
Her other medical problems include hypertension and type 2 diabetes mellitus, and she takes lisinopril and metformin. She does not use tobacco or illicit drugs. Vital signs and general examination are within normal limits. A recent chemistry panel was normal, and a recent hemoglobin A1c was 6.8%.
Which of the following is the best next step in management of this patient?

Question

A 45-year-old woman returns to the office for follow-up of depression.  Three months ago, she was diagnosed with major depressive disorder with suicidal ideation and was started on sertraline.  At her one-month follow-up, the patient had slight improvement with no suicidal ideation but reported sexual dysfunction with anorgasmia.  She has been in a mutually supportive relationship with a single partner for several years and had not experienced sexual dysfunction previously.  Her sertraline dose was decreased to help with this effect.  At today's visit the patient reports that her mood is "okay" but that she still has "more down days than not" and low energy.  She continues to suffer from anorgasmia, which is distressing and negatively affecting her relationship.
Her other medical problems include hypertension and type 2 diabetes mellitus, and she takes lisinopril and metformin.  She does not use tobacco or illicit drugs.  Vital signs and general examination are within normal limits.  A recent chemistry panel was normal, and a recent hemoglobin A1c was 6.8%.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98a9_1c93_853d_51c36cb9cb67_MD0002_00 All selective serotonin reuptake inhibitors (SSRIs) may be associated with sexual dysfunction in both women (decreased libido and anorgasmia) and men (ejaculatory dysfunction). There is no definitive evidence that one SSRI causes less sexual dysfunction than another. Treatment options include lowering the antidepressant dose if feasible, switching to another antidepressant, or augmenting with another agent. For patients with only modest response to an SSRI or with severe sexual dysfunction, switching agents rather than augmenting is preferable. This patient has had an inadequate antidepressant response and her sexual dysfunction persists despite a reduction in her sertraline dose. The best approach is to switch her medication to a non-SSRI antidepressant, such as bupropion or mirtazapine, which has no or limited effect on sexual function. Patients who are SSRI responders may benefit from adjunctive therapy with sildenafil (phosphodiesterase-5 inhibitor) or bupropion. (Choice B) Serotonin-norepinephrine reuptake inhibitors such as venlafaxine have also been associated with sexual dysfunction, making bupropion a better option. (Choice C) Decreasing the SSRI dose is most appropriate for patients in remission who are on high doses. This patient is already on a low dose of sertraline with only modest improvement, and further dose reduction would risk worsening her depression. (Choice D) When switching to bupropion, a dopamine-norepinephrine reuptake inhibitor, an SSRI should be tapered rather than stopped abruptly. This is because bupropion and sertraline have differing mechanisms of action and can require up to 6 weeks to take effect. Stopping the SSRI abruptly could result in discontinuation syndrome and a recurrence of depressive symptoms before bupropion can take effect. (Choice E) Watchful waiting may be a reasonable approach in an SSRI responder but would not be appropriate for this patient, who has only modest improvement. For most patients, SSRI-induced sexual side effects typically do not diminish over time. Educational objective: Selective serotonin reuptake inhibitors are often associated with sexual dysfunction. Treatment options include lowering the dose, switching to another antidepressant (eg, bupropion, mirtazapine), or augmenting with either bupropion or a phosphodiesterase inhibitor. __________ References: Reversal of SSRI-induced female sexual dysfunction by adjunctive bupropion in menstruating women: a double-blind, placebo-controlled and randomized study. (http://www.ncbi.nlm.nih.gov/pubmed/20080928) Antidepressant drugs and sexual dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/23732933)

A 45-Year-Old Woman Returns to the Office for Follow-Up of Depression