A 35-year-old man comes to the office due to sleep disturbance, low energy, and loss of appetite for the past 3 months. Further history indicates that he lost his job 6 months ago when his company was relocated overseas, and he has been feeling "too depressed and unmotivated" to look for new work. He has stopped exercising and prefers not to be around his friends, feeling embarrassed that he had to move back in with his parents. He has thoughts that "life is not worth living" but has no thoughts of suicide. Physical examination and laboratory evaluation are noncontributory. The patient is diagnosed with major depressive disorder and started on sertraline 25 mg.
At the patient's 2-week follow-up, he is tolerating the medication well, but his symptoms are unchanged. The dose is increased to 100 mg, which is within the therapeutic range. The patient phones 2 weeks later and requests to try another medication, saying, "Aside from sleeping and eating better, I still feel depressed."
Which of the following is the most appropriate course of action in management of this patient?

Question

A 35-year-old man comes to the office due to sleep disturbance, low energy, and loss of appetite for the past 3 months.  Further history indicates that he lost his job 6 months ago when his company was relocated overseas, and he has been feeling "too depressed and unmotivated" to look for new work.  He has stopped exercising and prefers not to be around his friends, feeling embarrassed that he had to move back in with his parents.  He has thoughts that "life is not worth living" but has no thoughts of suicide.  Physical examination and laboratory evaluation are noncontributory.  The patient is diagnosed with major depressive disorder and started on sertraline 25 mg.
At the patient's 2-week follow-up, he is tolerating the medication well, but his symptoms are unchanged.  The dose is increased to 100 mg, which is within the therapeutic range.  The patient phones 2 weeks later and requests to try another medication, saying, "Aside from sleeping and eating better, I still feel depressed."
Which of the following is the most appropriate course of action in management of this patient?

Quizplus · Accepted Answer

An adequate antidepressant trial is generally considered to be 6 weeks at a therapeutic dosage. Patients may be mistakenly labeled as treatment-resistant if they do not receive an adequate antidepressant trial. This patient has taken sertraline 100 mg for only 2 weeks and is beginning to show signs of response (eg, improvement in sleep and appetite). The physician should explain that 2 weeks at the 100-mg dosage is an inadequate trial and recommend that the patient continue sertraline for an additional 4 weeks. The initial 2-week period when the patient was on a subtherapeutic dose of 25 mg should not be counted as part of the trial. Physicians should be aware that inadequate dosage and/or duration is a common reason for perceived inefficacy. Patients may become easily discouraged, leading to nonadherence or premature medication changes and/or inappropriate polypharmacy on the part of the physician. To achieve a positive outcome, it is essential to explain the typical time course of antidepressant response and to encourage the patient to complete an adequate trial. (Choice A) Patients should receive an adequate trial of monotherapy before considering augmentation with a second medication. (Choices C and D) It would be premature to discontinue sertraline 100 mg after 2 weeks. Switching to an alternate antidepressant such as bupropion or venlafaxine can be considered if the patient has minimal response to a maximally tolerated dosage after 6 weeks. (Choice E) Increasing the dosage would not be indicated at this point as the patient is showing signs of responding to sertraline 100 mg. The dose should be maintained for the duration of an adequate trial. Increasing the dosage prematurely risks exposing the patient to unnecessary side effects. Educational objective: Patients with depression can be mistakenly labeled as treatment-resistant if they fail to receive an adequate antidepressant trial. Antidepressants should be continued for at least 6 weeks at a therapeutic dosage before considering medication augmentation or switching. __________ References: Evaluating antidepressant treatment prior to adding second-line therapies among patients with treatment-resistant depression. (http://www.ncbi.nlm.nih.gov/pubmed/26935957) Evidence-based pharmacotherapy of treatment-resistant unipolar depression. (http://www.ncbi.nlm.nih.gov/pubmed/27848269)

A 35-Year-Old Man Comes to the Office Due to Sleep