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."The patient returns for another follow-up 4 weeks later. He says, "At first, I really thought the medication was working and things were finally turning around for me. For a couple of weeks I felt less depressed, almost normal. I had more energy and was doing more activities with my kids and arguing less with my wife. Then I went on a long truck route halfway across the country, and things just started falling apart. Now, I'm not only depressed again, but I feel shaky and hyper at the same time. I needed to stay awake to drive for 16 hours straight, and then afterward I still couldn't fall asleep. My back has been hurting badly, too, and I had to take something stronger for the pain. One night, I even thought that my wife might be having an affair, but I know that's crazy!" On mental status examination, the patient is alert, anxious, and mildly tremulous. He has no suicidal thoughts. He is concerned that the sertraline has stopped working.
Which of the following is the most likely explanation for the patient's symptoms?

Question

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."The patient returns for another follow-up 4 weeks later.  He says, "At first, I really thought the medication was working and things were finally turning around for me.  For a couple of weeks I felt less depressed, almost normal.  I had more energy and was doing more activities with my kids and arguing less with my wife.  Then I went on a long truck route halfway across the country, and things just started falling apart.  Now, I'm not only depressed again, but I feel shaky and hyper at the same time.  I needed to stay awake to drive for 16 hours straight, and then afterward I still couldn't fall asleep.  My back has been hurting badly, too, and I had to take something stronger for the pain.  One night, I even thought that my wife might be having an affair, but I know that's crazy!"  On mental status examination, the patient is alert, anxious, and mildly tremulous.  He has no suicidal thoughts.  He is concerned that the sertraline has stopped working. 
Which of the following is the most likely explanation for the patient's symptoms?

Quizplus · Accepted Answer

Explanation: This patient has been on sertraline for a total of 7 weeks and showed significant signs of improvement prior to a road trip (ie, better mood, increased energy, improved interactions with his wife and children). When a patient appears to lose antidepressant response, a careful interim history that includes new psychosocial stresses, medical problems, and substances used should be obtained. Most likely, this patient's recent deterioration is due to increased substance use during his road trip. Although his alcohol use was not quantified previously, he is known to drink "a few" beers. He also uses energy drinks, is possibly using other stimulants to help him stay awake, and shows signs and symptoms of sympathetic activation (feeling "shaky" and "hyper," tremulousness on examination). He is also using pain medication other than naproxen. Alcohol, opiate, and other illicit substance use may be exacerbating his depression. Insomnia, hyperactivity, and paranoid ideation may be precipitated by amphetamines or other stimulants. A detailed substance use history will help to determine what substances may be contributing to his worsening depression and inadequate response to the antidepressant. (Choice A) The patient previously stated that he had no side effects on sertraline. Activating side effects (eg, insomnia, anxiety), if they occur, typically develop shortly after initiation of the antidepressant. (Choice B) Although antidepressant-induced mania should be considered, the time course of symptoms in relation to his trip and lack of history of manic symptoms at his age suggest that substance use is more likely. (Choice C) Although depressive relapse is a possibility, the patient's abrupt deterioration and signs of sympathetic activation (rather than return of fatigue that had characterized his depression) are more suggestive of a substance-related cause. (Choice D) This patient has no history of psychosis and has insight into his paranoid thoughts, suggesting that his symptoms are substance-induced. Educational objective: Depressed patients who deteriorate after initial signs of improvement on an antidepressant should be assessed carefully for substance use. Alcohol, stimulants, and opiates can exacerbate depressive symptoms and contribute to poor antidepressant response. References: Assessment and treatment of mood disorders in the context of substance abuse. (http://www.ncbi.nlm.nih.gov/pubmed/26246792)

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