A 28-year old woman comes to the office for follow-up due to depression. She was started on fluoxetine after developing low mood, loss of interest in activities, fatigue, hypersomnia, and carbohydrate craving for 4 weeks. After 8 weeks of treatment, the patient feels partially better but continues to struggle with low energy and weight gain. Although she functions adequately at work, she spends the rest of her time at home, feeling too tired and unmotivated to go out with friends or exercise. The patient has a history of antidepressant treatment for recurrent depressive episodes that start in the late fall and improve by the spring, when she feels significantly better. She usually stops taking medication for several months until the depression returns again. Physical examination is unremarkable. Which of the following is the most appropriate next step in management of this patient?

Question

A 28-year old woman comes to the office for follow-up due to depression.  She was started on fluoxetine after developing low mood, loss of interest in activities, fatigue, hypersomnia, and carbohydrate craving for 4 weeks.  After 8 weeks of treatment, the patient feels partially better but continues to struggle with low energy and weight gain.  Although she functions adequately at work, she spends the rest of her time at home, feeling too tired and unmotivated to go out with friends or exercise.  The patient has a history of antidepressant treatment for recurrent depressive episodes that start in the late fall and improve by the spring, when she feels significantly better.  She usually stops taking medication for several months until the depression returns again.  Physical examination is unremarkable.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's history of recurrent major depressive episodes with onset in the fall and remission in the spring is characteristic of major depressive disorder with seasonal pattern (also known as seasonal affective disorder [SAD]). SAD with fall-winter onset and spring-summer remission, the most common type of seasonal depression, is generally characterized by atypical features of depression such as increased sleep, increased appetite, carbohydrate craving, and weight gain. First-line treatment consists of antidepressants and bright light therapy. This patient has had a partial response to antidepressant therapy and would benefit from the addition of light therapy. Bright light therapy is typically administered with a 10,000-lux light box shortly after awakening. Most patients experience clinical improvement in 1-4 weeks and continue treatment through the fall or winter until spontaneous remission in the spring or summer. Light therapy alone is a reasonable alternative for patients with mild to moderate SAD. (Choice A) There is no evidence for the efficacy of antipsychotic augmentation (eg, aripiprazole) in patients with seasonal depression. (Choices C and D) Valproate and lithium are mood stabilizers used as first-line treatment for bipolar disorders. This patient's improvement in the spring is consistent with remission of depression and not with mood elevation in bipolar disorder. (Choice E) This patient's depression has partially responded to fluoxetine, so switching her medication could result in loss of efficacy. Because of their side effects and safety issues, monoamine oxidase inhibitor antidepressants (eg, phenelzine) are generally reserved for treatment-resistant depression. Educational objective: Major depressive disorder with seasonal pattern (seasonal affective disorder) is characterized by seasonal onset and remission (most commonly fall-winter onset and spring-summer remission). Treatment consists of bright light therapy alone or with an antidepressant. References: Seasonal affective disorder. (http://www.ncbi.nlm.nih.gov/pubmed/23198671) Seasonal affective disorder, winter type: current insights and treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/27942239)

A 28-Year Old Woman Comes to the Office for Follow-Up