A 38-year-old woman with type 2 diabetes mellitus comes to the office for follow-up. Although her laboratory results indicate good glycemic control, she describes low energy, fatigue, and difficulty concentrating at work. Further evaluation reveals that the patient has become increasingly depressed over the past month. She says, "All I do is work and then go home so I can get in bed and sleep. I feel bad that I stopped exercising. It takes too much effort see my friends or date and I have no interest in sex." The patient has no psychiatric history. Her sister takes paroxetine for depression and anxiety with good results.
Physical examination is unremarkable apart from a BMI of 27.9 kg/m² and a 2.26-kg (5-lb) weight gain since her last visit. Mental status examination shows depressed mood and affect and no suicidal ideation. The patient is diagnosed with major depressive disorder and treatment options are discussed.
Which of the following is the most appropriate pharmacotherapy for this patient?

Question

Quizplus · Accepted Answer

Although selective serotonin reuptake inhibitors (SSRIs) are commonly selected as initial treatment for major depressive disorder, other first-line pharmacotherapies for major depressive disorder include serotonin-norepinephrine reuptake inhibitors (SNRIs) (eg, venlafaxine), norepinephrine dopamine reuptake inhibitors (eg, bupropion), and serotonin modulators (eg, mirtazapine). Because efficacy is generally comparable across antidepressant classes, drug selection is based on other factors, including side effect profile, specific depressive symptoms, patient preference, and cost. This patient has diabetes and depressive symptoms that include low libido, weight gain, and hypersomnia. Bupropion would be a preferred medication choice: It induces fewer sexual side effects compared to other antidepressants; in addition, it is associated with the least weight gain and, in some cases, modest weight loss. In contrast, SSRIs and SNRIs are associated with weight gain and significant sexual side effects. Bupropion is also activating and would be a good choice in a patient with low energy and hypersomnia. Bupropion should be avoided in patients with seizures and active eating disorders due to its lowering of the seizure threshold. (Choices B, D, and E) These SSRI (escitalopram, paroxetine) and SNRI (venlafaxine) medications are not preferred for this patient as they are associated with weight gain and sexual side effects. Although the patient's sister responded to paroxetine, this particular drug has been associated with the most weight gain among the SSRIs. (Choice C) Although mirtazapine does not cause sexual dysfunction, it is associated with increased appetite, weight gain, and sedation, which would be problematic for this overweight, hypersomnic patient. Educational objective: Drug side effect profiles and specific depressive symptoms can help guide initial antidepressant medication selection. Bupropion, a norepinephrine dopamine reuptake inhibitor, is a first-line treatment for major depressive disorder that is associated with less weight gain and fewer sexual side effects compared with selective serotonin reuptake inhibitors. __________ References: Weight gain and glucose dysregulation with second-generation antipsychotics and antidepressants: a review for primary care physicians. (http://www.ncbi.nlm.nih.gov/pubmed/22913904) Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant. (http://www.ncbi.nlm.nih.gov/pubmed/27141292)

A 38-Year-Old Woman with Type 2 Diabetes Mellitus Comes to the Office