A 57-year-old woman comes to the office due to low mood and poor sleep for the past 2 months. She describes difficulty focusing at work and has been avoiding friends and family on weekends "because I don't feel up to being around people." Her appetite has increased and she finds it increasingly difficult to motivate herself to exercise. The patient has no suicidal ideation or psychosis. There is no psychiatric history. Medical history is significant for hypertension and seasonal allergies treated with hydrochlorothiazide and loratadine. Physical examination is normal apart from a 2.3-kg (5-lb) weight gain, and laboratory results, including thyroid function tests, are normal. The patient is diagnosed with major depressive disorder and started on sertraline 50 mg.
At her 1-month follow-up, the patient reports improvement in her sleep and energy level and is tolerating the medication well. However, she continues to feel sad more days than not and is unable to enjoy activities as she once did.
Which of the following is the most appropriate next step in management of this patient?

Question

A 57-year-old woman comes to the office due to low mood and poor sleep for the past 2 months.  She describes difficulty focusing at work and has been avoiding friends and family on weekends "because I don't feel up to being around people."  Her appetite has increased and she finds it increasingly difficult to motivate herself to exercise.  The patient has no suicidal ideation or psychosis.  There is no psychiatric history.  Medical history is significant for hypertension and seasonal allergies treated with hydrochlorothiazide and loratadine.  Physical examination is normal apart from a 2.3-kg (5-lb) weight gain, and laboratory results, including thyroid function tests, are normal.  The patient is diagnosed with major depressive disorder and started on sertraline 50 mg.
At her 1-month follow-up, the patient reports improvement in her sleep and energy level and is tolerating the medication well.  However, she continues to feel sad more days than not and is unable to enjoy activities as she once did.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient has had partial improvement in her depression after a 4-week trial of sertraline, a selective serotonin reuptake inhibitor (SSRI), at a dose of 50 mg. However, her sadness and anhedonia persist. The most appropriate intervention for a patient with good tolerability and inadequate response is to increase the dose within the therapeutic range. Sertraline is typically dosed at 50 mg initially but may be increased in increments of 25-50 mg, up to a maximum of 200 mg/day. Before augmentation strategies or switching to another antidepressant are considered, this patient's dose of sertraline should be increased. Switching to another antidepressant or implementing an augmentation strategy would be appropriate for patients who have failed an adequate trial of a maximally tolerated dose of an SSRI. (Choices A, B, and C) Pharmacologic strategies for treatment-resistant depression include augmentation with a second-generation antipsychotic (eg, aripiprazole), lithium, or triiodothyronine. Adding a second antidepressant from a different class, such as a norepinephrine dopamine reuptake inhibitor (eg, bupropion), may also be considered. However, this patient's depression should not be considered treatment-resistant, so it would be inappropriate to add a second medication prior to a trial of an increased SSRI dose. (Choice E) Switching to a serotonin norepinephrine reuptake inhibitor (eg, venlafaxine) would be an option if the patient fails to respond to a maximally tolerated dose of sertraline. Educational objective: Depressed patients with an inadequate response to a selective serotonin reuptake inhibitor should have their dose increased within the therapeutic range. Switching to an alternate antidepressant or augmenting with another class of antidepressant can be considered for patients who fail to respond to a maximally tolerated dose. __________ References: Psychopharmacology in primary care settings. (http://www.ncbi.nlm.nih.gov/pubmed/27262011) Systematic review and meta-analysis: dose-response relationship of selective serotonin reuptake inhibitors in major depressive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26552940)

A 57-Year-Old Woman Comes to the Office Due to Low