A 37-year-old man comes to the office for a follow-up visit. One month ago, he was diagnosed with type 2 diabetes mellitus and was started on metformin. Blood pressure is 130/80 mm Hg, fasting glucose is 122 mg/dL, and BMI is 29.1 kg/m². The patient looks rather dejected and admits that it has been difficult to come to terms with his diagnosis. He has tried to exercise, watch his oral intake, and quit smoking as was suggested, but lately he has felt unmotivated and without energy. The patient admits to feeling sad and guilty about his weight and smoking but is not sure he can do anything about it. He has been oversleeping and then spending much of the day in bed watching television or sleeping due to lack of energy. He has withdrawn from friends and family and took the last 2 weeks off from work because he did not "feel up to going." The patient's ability to concentrate and pay attention to daily tasks is significantly impaired. Which of the following is the most appropriate pharmacotherapy?

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This patient is suffering from a major depressive episode characterized by >2 weeks of depressed mood, anhedonia, sleep disturbance, guilt, and impaired energy, motivation and concentration. Because no antidepressant has demonstrated superior efficacy, choice of medication is often based on other factors such as side effect profile and medical and psychiatric comorbidity. Bupropion, a norepinephrine and dopamine reuptake inhibitor, is a preferred option as it is a first-line antidepressant with a favorable side effect profile for this patient. It has mild stimulant effects and therefore can increase wakefulness, energy, and concentration. Bupropion is an approved treatment for smoking cessation and can also help with weight loss. It does not cause sexual side effects. Bupropion is contraindicated in patients with a history of seizures and those with eating disorders. > (Choice A) Amitriptyline, a tricyclic antidepressant, is sedating and is not considered a first-line antidepressant due to its side effect profile (eg, cardiotoxicity, danger in overdose). (Choices B and D) Atomoxetine, a norepinephrine reuptake inhibitor, and methylphenidate, a stimulant, are used to treat attention-deficit hyperactivity disorder. This patient's impaired attention and concentration are symptoms of his depression. (Choice E) Mirtazapine, an antidepressant with serotonergic and noradrenergic activity, can be sedating and increase appetite. (Choice F) Modafinil is a wakefulness-promoting agent approved to treat narcolepsy. It has been used as an adjunct to improve motivation and energy in some patients with psychiatric illness. It is not an antidepressant and therefore not appropriate in this patient. (Choice G) Phenelzine, a monoamine oxidase inhibitor (MAOI), can cause weight gain and is not a first-line medication due to its dietary restrictions and potential for severe side effects (eg, hypertensive crisis, serotonin syndrome). Although MAOIs have been used to treat atypical depression (hyperphagia, hypersomnia, leaden paralysis, and rejection sensitivity), they are reserved for treatment-resistant cases. Educational objective: Bupropion is an antidepressant with mild stimulant properties that can be particularly helpful for depressed patients with low energy, impaired concentration, hypersomnia, and weight gain. It can also be used to aid smoking cessation. References: Bupropion hydrochloride. (http://www.ncbi.nlm.nih.gov/pubmed/26940167) Spotlight on bupropion in major depressive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/18547129) Bupropion and cognitive-behavioral treatment for depression in smoking cessation. (http://www.ncbi.nlm.nih.gov/pubmed/17577801)

A 37-Year-Old Man Comes to the Office for a Follow-Up