A 52-year-old man comes to the office for follow-up of depression. The patient was initially seen 6 months ago for symptoms of low energy, lack of motivation, anxiety, hypersomnia, increased appetite, weight gain, and poor concentration. At that time, he was having difficulty functioning at his job as an accountant and was worried about being fired for poor performance. Physical examination was unremarkable and routine laboratory tests were within normal limits. The patient was diagnosed with major depression and started on sertraline 50 mg. After several weeks, his dosage was gradually increased to 150 mg and he has steadily improved since then. The patient has a history of 2 prior major depressive episodes at ages 35 and 49 but was never treated.
At today's visit, he reports that his mood is "good" and that he is functioning well at home and at work. The patient is tolerating sertraline without difficulty and has no suicidal ideation. He asks how long he should continue the medication.
Which of the following is the most appropriate recommendation for this patient?

Question

A 52-year-old man comes to the office for follow-up of depression.  The patient was initially seen 6 months ago for symptoms of low energy, lack of motivation, anxiety, hypersomnia, increased appetite, weight gain, and poor concentration.  At that time, he was having difficulty functioning at his job as an accountant and was worried about being fired for poor performance.  Physical examination was unremarkable and routine laboratory tests were within normal limits.  The patient was diagnosed with major depression and started on sertraline 50 mg.  After several weeks, his dosage was gradually increased to 150 mg and he has steadily improved since then.  The patient has a history of 2 prior major depressive episodes at ages 35 and 49 but was never treated.
At today's visit, he reports that his mood is "good" and that he is functioning well at home and at work.  The patient is tolerating sertraline without difficulty and has no suicidal ideation.  He asks how long he should continue the medication.
Which of the following is the most appropriate recommendation for this patient?

Quizplus · Accepted Answer

Following response to acute treatment, patients with a single episode of unipolar major depression should continue antidepressants for an additional 6 months. However, patients with a history of multiple depressive episodes (ie, recurrent major depression) are at high risk for recurrence and are candidates for maintenance antidepressant treatment. Other risk factors for recurrence include early age of onset (≤18), persistent residual depressive symptoms, and comorbid psychiatric disorders. Patients with an increased risk of recurrence should be maintained on antidepressants for at least an additional 1-3 years to reduce risk of relapse and can also consider continuing treatment indefinitely. Those with a history of highly recurrent illness (eg, ≥3 lifetime depressive episodes), chronic episodes (≥2 years), or severe episodes (eg, suicide attempts) are particularly good candidates for maintaining antidepressant treatment indefinitely. This patient has a history of 2 prior episodes of major depression and would be an appropriate candidate for maintenance pharmacotherapy. For such patients, it may be helpful to conceptualize recurrent major depression as a chronic illness similar to other chronic medical diseases (eg, hypertension) that may also require long-term medications. (Choices A, B, D, and E) This patient should continue antidepressant medication for an additional 1-3 years due to his increased risk of recurrence. If the decision is made to discontinue medication, a gradual taper over several weeks to months is preferable. Patients with a history of recurrent episodes who discontinue antidepressants should be monitored closely, and antidepressant therapy should be reinstituted at the first signs of recurrence. Educational objective: Maintenance antidepressant pharmacotherapy (1-3 years) is indicated for patients with recurrent episodes. Patients with ≥3 lifetime depressive episodes, severe episodes (eg, suicide attempts), or episodes lasting ≥2 years can be maintained on treatment indefinitely. __________ References: Rationale for, barriers to, and appropriate medication for the long-term treatment of depression. (http://www.ncbi.nlm.nih.gov/pubmed/20371029)

A 52-Year-Old Man Comes to the Office for Follow-Up of Depression