A 46-Year-Old Truck Driver Comes to the Office Due to Fatigue

A 46-year-old truck driver comes to the office due to fatigue.  He has consumed energy drinks during the past 3 months to complete his driving routes.  He sleeps most of the day on weekends and avoids his wife and kids.  The patient says, "I even slept through my son's baseball game.  I felt really bad about that."  He has a history of chronic back and knee pain due to a motorcycle accident.  The patient's medications include naproxen.  He drinks a few beers with friends but has not socialized much lately.  The patient's wife says that he is never there for her and they fight constantly.  He has no history of manic symptoms or other psychiatric history.  Physical examination and routine laboratory studies are unremarkable.  Mental status examination shows depressed mood and sad affect.  The patient says he has had thoughts of suicide but would never do anything because of his children.  He is diagnosed with depression and started on sertraline.  He returns for a 3-week follow-up, reporting little change.  The patient says, "Some days I think I'm feeling a little better, but other days are really bad.  I don't know about these pills.  I've been taking them and don't have any side effects, but I still feel pretty bad."
Which of the following is the most appropriate response?

A) Are you having any difficulty taking the medication regularly?
B) I understand you are still struggling, but it takes time for these medicines to take full effect.
C) It can be frustrating when improvement is slow, but we can add another medication to boost your response.
D) We can consider switching to another antidepressant because you are not improving.
E) We can stop the medication and try psychotherapy instead.