A 38-year-old woman comes to the office for follow-up of major depressive disorder. She was first seen 2 weeks ago for low mood and irritability, loss of interest, difficulty falling and staying asleep, decreased appetite, and poor concentration at work. At that time, she was started on a therapeutic dosage of escitalopram and weekly psychotherapy. The patient had mild nausea for several days after starting the medication but is now tolerating it without difficulty. She says, "I'm afraid the medication isn't working as well anymore. At first my sleep and appetite were better, but for the past few days I feel like I might be slipping back to where I started." The patient reports that she is stressed because her husband is away on business this week and her father was recently hospitalized for a stroke. Mental status examination shows a mildly depressed mood and sad affect. Which of the following is the most appropriate next step in pharmacological management?

Question

A 38-year-old woman comes to the office for follow-up of major depressive disorder.  She was first seen 2 weeks ago for low mood and irritability, loss of interest, difficulty falling and staying asleep, decreased appetite, and poor concentration at work.  At that time, she was started on a therapeutic dosage of escitalopram and weekly psychotherapy.  The patient had mild nausea for several days after starting the medication but is now tolerating it without difficulty.  She says, "I'm afraid the medication isn't working as well anymore.  At first my sleep and appetite were better, but for the past few days I feel like I might be slipping back to where I started."  The patient reports that she is stressed because her husband is away on business this week and her father was recently hospitalized for a stroke.  Mental status examination shows a mildly depressed mood and sad affect.  Which of the following is the most appropriate next step in pharmacological management?

Quizplus · Accepted Answer

Assessment of antidepressant medication response requires that the patient has had an adequate trial in both dose and duration. An adequate antidepressant trial is generally considered to be at least 4-6 weeks at a therapeutic dosage. This patient has taken escitalopram for only 2 weeks, which is considered an inadequate trial in duration. Her lack of sustained improvement after 2 weeks is not uncommon, and her symptoms over the past week are likely related in part to psychosocial stress (father hospitalized, husband away). The most appropriate step in pharmacotherapy is to continue the trial of escitalopram at the current dosage. Increasing the dosage is unnecessary and risks exposing the patient to additional side effects (Choice E). The patient should be educated that 2 weeks is considered an inadequate trial and encouraged to continue the medication for at least 2-4 more weeks. Patients should receive an adequate antidepressant trial before next-step treatments are recommended, such as augmentation with a second medication or switching to an alternate antidepressant. (Choices A and B) It would be premature to add amitriptyline at bedtime or aripiprazole after only 2 weeks of escitalopram. These augmentation strategies could be considered in a patient who has failed an adequate trial of monotherapy. (Choices C and D) Discontinuing antidepressant medication at the 2-week point would be premature. Switching to an alternate antidepressant can be considered for patients with minimal response after an adequate trial of 4-6 weeks or for those unable to tolerate the medication. Trazodone is a very sedating medication that is often difficult to tolerate in dosages required to treat depression. Educational objective: An antidepressant trial is at least 4-6 weeks at a therapeutic dose. Physicians should continue antidepressants for at least 4-6 weeks before considering the next step in treatment. References: Evaluating antidepressant treatment prior to adding second-line therapies among patients with treatment-resistant depression. (http://www.ncbi.nlm.nih.gov/pubmed/26935957)

A 38-Year-Old Woman Comes to the Office for Follow-Up of Major