A 32-year-old man comes to the office for follow-up. Two weeks ago, he was evaluated for depressed mood, low energy, and poor concentration at work. The patient had difficulty getting out of bed in the mornings and called in sick to work 3 days in a row. Routine laboratory testing and physical examination were normal, and he was diagnosed with major depressive disorder. The patient was started on fluoxetine, which he has taken for the past 2 weeks. At today's follow-up visit, he reports that although still somewhat depressed, he feels more energetic and a little better overall. He says, "I have more energy, and it's a little easier to get motivated to go to work now." However, he reports new symptoms of mild nausea and occasional anxiety and restlessness. He also had difficulty sleeping one night, which is unusual for him as he previously was oversleeping. The patient drinks a glass of wine daily but does not use tobacco or illicit drugs. He is a sales representative and reports missing no workdays this past week. Vital signs are stable, and his physical examination is unchanged. Which of the following is the most appropriate next step in management of this patient?

Question

A 32-year-old man comes to the office for follow-up.  Two weeks ago, he was evaluated for depressed mood, low energy, and poor concentration at work.  The patient had difficulty getting out of bed in the mornings and called in sick to work 3 days in a row.  Routine laboratory testing and physical examination were normal, and he was diagnosed with major depressive disorder.  The patient was started on fluoxetine, which he has taken for the past 2 weeks.  At today's follow-up visit, he reports that although still somewhat depressed, he feels more energetic and a little better overall.  He says, "I have more energy, and it's a little easier to get motivated to go to work now."  However, he reports new symptoms of mild nausea and occasional anxiety and restlessness.  He also had difficulty sleeping one night, which is unusual for him as he previously was oversleeping.  The patient drinks a glass of wine daily but does not use tobacco or illicit drugs.  He is a sales representative and reports missing no workdays this past week.  Vital signs are stable, and his physical examination is unchanged.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient reports some improvement of his depression as well as new symptoms that are likely early side effects of the selective serotonin reuptake inhibitor (SSRI) fluoxetine (ie, nausea, anxiety, insomnia). Gastrointestinal and activating side effects are common at the start of SSRI treatment, and tolerance typically develops over several weeks. In contrast, SSRI-related sexual dysfunction often does not respond to watchful waiting. Given that this patient is showing signs of improvement and mild side effects that will likely improve over time, the best approach is to continue fluoxetine for an additional 4 weeks. At that point, he will have had an adequate trial (6 weeks) and can be assessed for response and side effect resolution. Prematurely adding medications to counteract side effects or switching the antidepressant at the 2-week follow-up would risk additional side effects and/or loss of the initial antidepressant response. (Choice A) This patient's intermittent anxiety and insomnia are side effects that will likely improve with continued treatment. Adding a benzodiazepine is inappropriate and carries risks of abuse and dependence. (Choice B) Mirtazapine is a sedating antidepressant that can be used as a first-line medication or an adjunct to SSRIs. However, this patient's depressive symptoms are improving and his insomnia is not persistent. It would be premature to add this antidepressant after 2 weeks of fluoxetine. (Choice C) Patients with depression should be advised to use caution when consuming alcohol due to its potential depressant effects. However, this patient's depression is improving, and it is unlikely that his moderate alcohol consumption is significantly affecting his symptoms. (Choice E) Bupropion, a norepinephrine dopamine reuptake inhibitor, is a first-line antidepressant that could be considered if the patient had persistent, intolerable side effects and/or failed an adequate trial of fluoxetine. Educational objective: Gastrointestinal and activating side effects are common at the start of therapy with selective serotonin reuptake inhibitors and often improve. Patients should continue the medication for 6 weeks (adequate trial) if the side effects are tolerable. Patients with intolerable side effects and/or an inadequate response following an adequate trial should switch to a different antidepressant. References: Toward achieving optimal response: understanding and managing antidepressant side effects. (http://www.ncbi.nlm.nih.gov/pubmed/19170398)

A 32-Year-Old Man Comes to the Office for Follow-Up