A 40-year-old woman with major depression comes to the office for follow-up. She has been taking paroxetine daily for the past year. The patient is doing fairly well but is concerned that she experiences periods of low mood on occasion. When asked how she is taking the medication, she states, "I know the bottle says once a day, but I usually take an extra pill when I feel sad and skip it if I'm having a good day." Vitals signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Question

A 40-year-old woman with major depression comes to the office for follow-up.  She has been taking paroxetine daily for the past year.  The patient is doing fairly well but is concerned that she experiences periods of low mood on occasion.  When asked how she is taking the medication, she states, "I know the bottle says once a day, but I usually take an extra pill when I feel sad and skip it if I'm having a good day."  Vitals signs are within normal limits.  Physical examination shows no abnormalities.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

This patient is not adhering to the prescribed medication schedule and appears to not understand the importance of consistent dosing or the risks of doubling or skipping her dose. Her occasional periods of low mood may reflect inconsistent dosing; the most appropriate step in management is to explain that daily medication adherence is necessary to achieve the steady-state blood level required to sustain improvement in depression. In addition to possible loss of efficacy, the physician should also educate this patient about the risks associated with skipping or doubling the dose of paroxetine, including antidepressant withdrawal syndrome (eg, dizziness, myalgia, nausea, headache), increased adverse effects, drug interactions, and toxicity in serious cases. If a dose is missed, the patient should be instructed not to double the next dose. Other strategies to improve consistent dosing include using the simplest regimen and least frequent dosing possible and using labeled pill boxes or reminder cues (eg, phone alarm, pairing with another daily activity). (Choice B) This approach may be perceived as judgmental and does not educate the patient about why consistent dosing is important. (Choice C) Serum levels of selective serotonin reuptake inhibitors are not routinely used. A paroxetine level can help confirm that the patient is taking the medication but does not indicate how much or in what way it is being taken, and does not help guide treatment. Addressing the patient's misconceptions about the medication is preferable. (Choices D and E) This patient has already acknowledged that she knows she should take the medication daily. Providing oral or written instructions or recommending that she take the medication as prescribed does not address her lack of understanding that antidepressants should not be taken as needed and require consistent dosing to sustain efficacy. Educational objective: Inconsistent dosing due to patient misconceptions regarding antidepressant use can result in loss of efficacy and the potential for toxicity and withdrawal. Physicians must assess the patient's understanding and provide targeted education to address misconceptions. __________ References: How can we improve antidepressant adherence in the management of depression? A targeted review and 10 clinical recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/32491040)

A 40-Year-Old Woman with Major Depression Comes to the Office