A 24-year-old woman comes to the office due to low energy and poor concentration. She says, "I don't know what is wrong with me. Nothing bad has happened, but over the past month I've felt really down and exhausted all the time. Last weekend, I didn't even get out of bed all day. Luckily, I work from home, so I don't even shower or get dressed. I stare at the computer all day, unable to concentrate or get any work done." At night, the patient has difficulty falling asleep, awakens at 4:00 AM, and has difficulty getting back to sleep. She has no appetite and eats only cereal as shopping and preparing food take too much effort. The patient has a psychiatric history of attention deficit hyperactivity disorder as a child, which was treated successfully. She has no medical history. Her medications include oral contraceptives and ibuprofen for menstrual cramps. The patient does not use tobacco or illicit drugs. She usually drinks a glass of wine each day but admits that for the past couple of weeks she has had a second glass at bedtime to help her fall asleep. There is a family history of alcoholism in her father and uncle. Other than a 3.1-kg (6.8-lb) weight loss since her last visit, physical examination is normal. Mental status examination is remarkable for soft, slowed speech and several lapses in concentration during the interview. She has no suicidal ideation. Complete blood count, serum chemistry panel, and TSH are within normal range. Which of the following is the most appropriate next step in management of this patient?

Question

A 24-year-old woman comes to the office due to low energy and poor concentration.  She says, "I don't know what is wrong with me.  Nothing bad has happened, but over the past month I've felt really down and exhausted all the time.  Last weekend, I didn't even get out of bed all day.  Luckily, I work from home, so I don't even shower or get dressed.  I stare at the computer all day, unable to concentrate or get any work done."  At night, the patient has difficulty falling asleep, awakens at 4:00 AM, and has difficulty getting back to sleep.  She has no appetite and eats only cereal as shopping and preparing food take too much effort.  The patient has a psychiatric history of attention deficit hyperactivity disorder as a child, which was treated successfully.  She has no medical history.  Her medications include oral contraceptives and ibuprofen for menstrual cramps.  The patient does not use tobacco or illicit drugs.  She usually drinks a glass of wine each day but admits that for the past couple of weeks she has had a second glass at bedtime to help her fall asleep.  There is a family history of alcoholism in her father and uncle.  Other than a 3.1-kg (6.8-lb) weight loss since her last visit, physical examination is normal.  Mental status examination is remarkable for soft, slowed speech and several lapses in concentration during the interview.  She has no suicidal ideation.  Complete blood count, serum chemistry panel, and TSH are within normal range.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient's >2-week history of depressed mood, low energy, early morning awakening, impaired concentration, decreased appetite, and weight loss are consistent with major depressive disorder. Treatment options for major depression include antidepressant pharmacotherapy, psychotherapy, or a combination of the two. First-line antidepressants include selective serotonin reuptake inhibitors (eg, escitalopram), serotonin norepinephrine reuptake inhibitors (eg, venlafaxine), and atypical antidepressants (eg, bupropion, mirtazapine). Studies support the use of cognitive-behavioral therapy and interpersonal psychotherapy over other purely supportive psychotherapies. Factors in treatment selection include severity of the depression, availability of psychotherapy, and patient preference. Patients with more severe levels of depression benefit from pharmacotherapy in combination with psychotherapy or pharmacotherapy alone. This patient is seeking medical help for moderately severe symptoms of depression that are causing significant functional impairment. The absence of psychosocial stressors, pronounced neurovegetative features (ie, fatigue, early morning awakening, psychomotor retardation, weight loss), and markedly impaired concentration suggest that pharmacotherapy would be a reasonable initial approach. (Choice A) There is no evident temporal relationship between the patient's use of hormonal contraceptives and the onset of her recent depression. Although hormonal contraceptives have been linked to depression in some studies, the data are inconclusive. (Choice C) Although the patient has a history of attention deficit hyperactivity disorder, she is currently experiencing major depression. The psychostimulant methylphenidate is not a first-line pharmacotherapy for major depressive disorder. (Choice D) This patient's depression preceded her increased alcohol consumption. Depressed patients may use alcohol to self-medicate their insomnia. This, in turn, typically worsens insomnia by causing more nighttime awakenings. The patient should be instructed to decrease or eliminate her alcohol use, but this intervention alone would not adequately address her depression. (Choice E) Patients with moderate to severe depression typically require pharmacotherapy in addition to supportive psychotherapy. It may be difficult for this patient to fully engage in therapy until her pronounced lethargy and impaired concentration begin to improve. Educational objective: Treatment options for major depression include pharmacotherapy, psychotherapy, or a combination of the two. Initial treatment with an antidepressant is indicated for patients with moderate-to-severe depression or if psychotherapy is not accessible or available. Cognitive-behavioral therapy and interpersonal psychotherapy have the best evidence among psychotherapies. References: Personalized treatment of adult depression: medication, psychotherapy, or both? A systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/22815247)

A 24-Year-Old Woman Comes to the Office Due to Low