A 58-year-old woman comes to the office due to depressed mood and hopelessness for the past 2 months. She has no interest in her hobbies or exercising and feels emotionally detached from her family and friends. The patient awakens every night at 2 AM and is up for the day at 4 AM. Her appetite is poor, and her children and husband have to remind her to eat. Her symptoms have caused her to take a leave of absence from work, and she has difficulty sustaining her attention to read a book or follow a television program. She has no suicidal thoughts. The patient has a history of depression beginning at age 22 and has had 5 lifetime episodes of major depression with one psychiatric hospitalization following a suicide attempt at age 32. She has not been hospitalized since then. Previous treatments have included paroxetine, escitalopram, and venlafaxine. She is not on any medication currently. Major depressive disorder is diagnosed, and the patient is started on venlafaxine as she recalls having an excellent response to this medication in the past. At her 2-week follow-up, she is showing signs of improvement. Which of the following is the most appropriate treatment plan for this patient?

Question

A 58-year-old woman comes to the office due to depressed mood and hopelessness for the past 2 months.  She has no interest in her hobbies or exercising and feels emotionally detached from her family and friends.  The patient awakens every night at 2 AM and is up for the day at 4 AM.  Her appetite is poor, and her children and husband have to remind her to eat.  Her symptoms have caused her to take a leave of absence from work, and she has difficulty sustaining her attention to read a book or follow a television program.  She has no suicidal thoughts.  The patient has a history of depression beginning at age 22 and has had 5 lifetime episodes of major depression with one psychiatric hospitalization following a suicide attempt at age 32.  She has not been hospitalized since then.  Previous treatments have included paroxetine, escitalopram, and venlafaxine.  She is not on any medication currently.  Major depressive disorder is diagnosed, and the patient is started on venlafaxine as she recalls having an excellent response to this medication in the past.  At her 2-week follow-up, she is showing signs of improvement.  Which of the following is the most appropriate treatment plan for this patient?

Quizplus · Accepted Answer

Major depressive disorder is a highly recurrent illness for most patients. Due to the high risk of recurrence, patients with ≥2 episodes are candidates for maintenance antidepressant treatment (ie, continuing antidepressants beyond the continuation phase of ~6 months following remission). Other indications for maintenance therapy (due to high risk of recurrence) include early age of onset (≤18), persistent residual depressive symptoms, and comorbid psychiatric disorders. Maintenance therapy can be continued for ~1-3 years. However, patients with a history of highly recurrent illness (eg, ≥3 lifetime depressive episodes), chronic episodes (≥2 years), severe ongoing psychosocial stressors, or severe episodes (eg, suicide attempts) are candidates for maintaining antidepressant treatment indefinitely. This patient's highly recurrent and severe episodes (ie, 5 previous major depressive episodes and a suicide attempt) make her an appropriate candidate for maintaining antidepressant pharmacotherapy indefinitely. Recurrent major depression may be conceptualized as a chronic illness similar to other chronic medical diseases (eg, hypertension, diabetes) that often require long-term medications. (Choice A) The dose that achieves remission should be maintained. Reducing the dose had been associated with an increased risk of recurrence. (Choices B, C, and D) Given the highly recurrent nature of this patient's illness, maintenance pharmacotherapy is indicated. 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: Major depressive disorder is often a recurrent illness. Patients with ≥3 lifetime depressive episodes, severe episodes (eg, suicide attempts), or episodes lasting ≥2 years are candidates for lifelong antidepressant treatment. References: Rationale for, barriers to, and appropriate medication for the long-term treatment of depression. (http://www.ncbi.nlm.nih.gov/pubmed/20371029) Predicting relapse after antidepressant withdrawal - a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/27786144) Review of maintenance trials for major depressive disorder: a 25-year perspective from the US Food and Drug Administration. (http://www.ncbi.nlm.nih.gov/pubmed/24717376) Recurrence of major depressive disorder and its predictors in the general population: results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). (http://www.ncbi.nlm.nih.gov/pubmed/23111147)

A 58-Year-Old Woman Comes to the Office Due to Depressed