A 45-year-old man comes to the office with low energy, depressed mood, sleep disturbance, and loss of interest and motivation. He is worried that he may lose his job due to repeated absences and low productivity. The patient has no suicidal ideation or psychotic features. There is no psychiatric history. After a thorough evaluation he is diagnosed with major depressive disorder. He is started on bupropion 150 mg, which is subsequently increased to 300 mg at his 2-week follow-up visit.
At his 6 week follow-up, the patient reports feeling much better and is back to his baseline. He is more productive at work and is considering applying for a promotion. The patient is tolerating bupropion without difficulty but mentions, "I hate taking medication everyday. How long do I have to take this stuff?"
Which of the following is the most appropriate recommendation?

Question

A 45-year-old man comes to the office with low energy, depressed mood, sleep disturbance, and loss of interest and motivation.  He is worried that he may lose his job due to repeated absences and low productivity.  The patient has no suicidal ideation or psychotic features.  There is no psychiatric history.  After a thorough evaluation he is diagnosed with major depressive disorder.  He is started on bupropion 150 mg, which is subsequently increased to 300 mg at his 2-week follow-up visit.
At his 6 week follow-up, the patient reports feeling much better and is back to his baseline.  He is more productive at work and is considering applying for a promotion.  The patient is tolerating bupropion without difficulty but mentions, "I hate taking medication everyday.  How long do I have to take this stuff?"
Which of the following is the most appropriate recommendation?

Quizplus · Accepted Answer

This patient has had an excellent response to acute-phase treatment with bupropion. To reduce the risk of depressive relapse, multiple guidelines recommend that patients with a single episode of major depressive disorder should continue antidepressant treatment for approximately 6 months following acute response (referred to as "continuation phase treatment"). If complete remission is maintained at the end of this period, the antidepressant can be gradually tapered and discontinued. Continuing the antidepressant beyond the acute phase is also helpful in resolving residual symptoms of depression and improving psychosocial functioning in patients who may be significantly improved but still mildly symptomatic. In contrast to this case, patients with a history of multiple episodes (recurrent major depressive disorder), chronic episodes (>2 years), or severe episodes (eg, suicide attempt) should be considered for maintenance treatment. This typically involves continuing antidepressant medication for 1-3 years following remission to reduce the risk of recurrence (Choice D). Continuing maintenance treatment indefinitely should be considered in patients with a history of highly recurrent (eg, >3 lifetime episodes) and very severe/chronic major depressive episodes. (Choice A) Antidepressant dose reduction during the continuation phase has been shown to increase the risk of relapse. The dose should be maintained (ie, the dose that gets the patient better keeps the patient better). (Choices C and E) Tapering the dose is preferable to abrupt discontinuation to prevent withdrawal symptoms (eg, dizziness, nausea, irritability, insomnia). However, this patient should be advised to remain on his medication for an additional 6 months to prevent relapse. Educational objective: Patients with a first episode of major depressive disorder should continue antidepressants for an additional 6 months following acute response to reduce the risk of relapse. Maintenance treatment (1-3 years or indefinitely) should be considered for patients with recurrent, severe/chronic episodes. __________ References: Duration of initial antidepressant treatment and subsequent relapse of major depression. (http://www.ncbi.nlm.nih.gov/pubmed/25502491) World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders. (http://www.ncbi.nlm.nih.gov/pubmed/23879318) Antidepressant dose reduction and the risk of relapse in major depressive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/17700046)

A 45-Year-Old Man Comes to the Office with Low Energy