A 45-year-old man comes to the office due to poor sleep. The patient describes difficulty falling asleep and awakening multiple times a night because he is worried about losing his job. For the past month, the patient has also had difficulties concentrating and has become increasingly anxious about his work performance. He says, "I've missed several deadlines and made a big mistake in accounting. How will I support my family if I get fired?" The patient feels exhausted when he awakens and has to force himself to get out of bed and get dressed. He has stopped cycling with his friends and has lost interest in other hobbies. Vital signs and physical examination are unremarkable apart from a 4.5-kg (10-lb) weight loss. Laboratory studies, including thyroid function tests, are within normal limits. The patient appears nervous and restless. He has no suicidal ideation. Which of the following is the most effective treatment for this patient?

Question

A 45-year-old man comes to the office due to poor sleep.  The patient describes difficulty falling asleep and awakening multiple times a night because he is worried about losing his job.  For the past month, the patient has also had difficulties concentrating and has become increasingly anxious about his work performance.  He says, "I've missed several deadlines and made a big mistake in accounting.  How will I support my family if I get fired?"  The patient feels exhausted when he awakens and has to force himself to get out of bed and get dressed.  He has stopped cycling with his friends and has lost interest in other hobbies.  Vital signs and physical examination are unremarkable apart from a 4.5-kg (10-lb) weight loss.  Laboratory studies, including thyroid function tests, are within normal limits.  The patient appears nervous and restless.  He has no suicidal ideation.  Which of the following is the most effective treatment for this patient?

Quizplus · Accepted Answer

This patient's 1-month history of loss of interest, sleep disturbance, low energy, impaired concentration, weight loss, and psychomotor agitation on examination are consistent with major depressive disorder (MDD). Treatment options for the initial treatment of MDD include antidepressants, psychotherapy, or a combination of both. The combination of an antidepressant and psychotherapy is more effective than either alone. Factors in treatment selection include patient preference, availability of psychotherapy, comorbidity, psychosocial issues, and cost. Antidepressant efficacy is generally comparable across and within classes and is comparable to psychotherapy alone. Most patients are treated with a selective serotonin reuptake inhibitor (eg, escitalopram) for a first episode, but other classes (eg, serotonin-norepinephrine reuptake inhibitors, serotonin modulators, norepinephrine-dopamine reuptake inhibitors) can be used. Cognitive-behavioral therapy and interpersonal psychotherapy have the best evidence for efficacy among psychotherapies and benefits that extend beyond the acute treatment period. (Choices A and B) Although this patient has significant anxiety, it is an associated symptom of his MDD, which is best treated with an antidepressant medication. Alprazolam and buspirone are used in the treatment of primary anxiety disorders and do not have antidepressant properties. In addition, supportive psychotherapy and psychodynamic therapy, although helpful for depression, are less well studied compared to cognitive-behavioral therapy. (Choices C and E) Although citalopram or fluoxetine is an appropriate first-line antidepressant choice, combination treatment with an antipsychotic (eg, aripiprazole) or a second antidepressant (eg, bupropion) is not indicated for initial treatment of uncomplicated depression. Aripiprazole and bupropion can be used as adjuncts to an antidepressant in treatment-resistant cases. Educational objective: First-line treatment options for major depressive disorder include antidepressants, psychotherapy, or a combination of both. Among psychotherapies, cognitive-behavioral therapy and interpersonal psychotherapy have the best evidence for efficacy. References: Major depressive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/27629598) Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24497254)

A 45-Year-Old Man Comes to the Office Due to Poor