A 21-year-old woman comes to the office due to poor sleep and depression. She has been feeling progressively depressed and unmotivated over the past month, and also describes decreased appetite, a 2.2-kg (5-lb) weight loss, poor concentration, and low energy. The patient has no suicidal ideation or manic or psychotic symptoms. She drinks 1 or 2 beers twice a week but does not use illicit drugs. She has never felt like this before and is worried as her symptoms have worsened to the point that she has trouble getting out of bed and attending college. Major depressive disorder is diagnosed, and the patient is started on citalopram 20 mg. One month later, she returns for a follow-up visit. She now reports feeling much better, has improved energy and sleep, and has returned to school. The patient has no side effects from the medication and wonders how long she should continue it. Which of the following is the most appropriate recommendation?

Question

A 21-year-old woman comes to the office due to poor sleep and depression.  She has been feeling progressively depressed and unmotivated over the past month, and also describes decreased appetite, a 2.2-kg (5-lb) weight loss, poor concentration, and low energy.  The patient has no suicidal ideation or manic or psychotic symptoms.  She drinks 1 or 2 beers twice a week but does not use illicit drugs.  She has never felt like this before and is worried as her symptoms have worsened to the point that she has trouble getting out of bed and attending college.  Major depressive disorder is diagnosed, and the patient is started on citalopram 20 mg.  One month later, she returns for a follow-up visit.  She now reports feeling much better, has improved energy and sleep, and has returned to school.  The patient has no side effects from the medication and wonders how long she should continue it.  Which of the following is the most appropriate recommendation?

Quizplus · Accepted Answer

Explanation: This patient has a first episode of major depression that has responded to acute treatment with citalopram. To reduce the risk of depressive relapse, guidelines recommend that patients with a single episode of major depressive disorder should continue antidepressant treatment for approximately 6 months following acute response (referred to as "continuation phase treatment"). The dosage that achieved response should be maintained and not reduced (ie, the dose that gets the patient well keeps the patient well) (Choice A). Patients with a history of multiple episodes (recurrent major depressive disorder), chronic episodes (≥2 years), strong family history, or severe episodes (eg, suicide attempt) should be considered for maintenance treatment. This typically involves continuing antidepressant medication for 1-3 years following remission to reduce the risk of recurrence (Choice D). Patients with a history of highly recurrent (eg, ≥3 lifetime episodes) and very severe, chronic major depressive episodes may need to continue maintenance treatment indefinitely. (Choices B and E) Discontinuing the antidepressant in several weeks or in 2 months would increase the patient's risk for relapse. Antidepressants should be continued for approximately 6 months into the continuation phase. Ideally, they should be tapered when discontinued. Educational objective: Patients with a single episode of major depressive disorder should continue antidepressants at the same dosage for an additional 6 months following acute response to reduce the risk of relapse. Those with recurrent, chronic, or severe episodes should be considered for maintenance treatment (1-3 years or indefinitely) to reduce the risk of recurrence. References: Duration of initial antidepressant treatment and subsequent relapse of major depression. (http://www.ncbi.nlm.nih.gov/pubmed/25502491) Antidepressant dose reduction and the risk of relapse in major depressive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/17700046)

A 21-Year-Old Woman Comes to the Office Due to Poor