A 42-year-old man comes to the office due to persistent sadness, weight gain, and fatigue over the past 4 months. The patient is a dentist who has had difficulty waking up in the morning for clinic. He says, "I used to be really efficient, but now I always run 2 hours behind schedule." He has been eating "lots of fast food" for dinner and feels exhausted every day. Following a divorce 3 years ago, the patient was diagnosed with major depressive disorder, which improved after a few months of treatment with paroxetine. The patient has a history of separation anxiety disorder as a child, which resolved with psychotherapy. Family history is significant for generalized anxiety disorder in his mother. Physical examination and laboratory evaluation are normal. After discussion of treatment options, the patient decides to start sertraline. His symptoms resolve by the follow-up appointment 6 months later. Which of the following features is an indication for long-term maintenance of antidepressant therapy in this patient?

Question

A 42-year-old man comes to the office due to persistent sadness, weight gain, and fatigue over the past 4 months.  The patient is a dentist who has had difficulty waking up in the morning for clinic.  He says, "I used to be really efficient, but now I always run 2 hours behind schedule."  He has been eating "lots of fast food" for dinner and feels exhausted every day.  Following a divorce 3 years ago, the patient was diagnosed with major depressive disorder, which improved after a few months of treatment with paroxetine.  The patient has a history of separation anxiety disorder as a child, which resolved with psychotherapy.  Family history is significant for generalized anxiety disorder in his mother.  Physical examination and laboratory evaluation are normal.  After discussion of treatment options, the patient decides to start sertraline.  His symptoms resolve by the follow-up appointment 6 months later.  Which of the following features is an indication for long-term maintenance of antidepressant therapy in this patient?

Quizplus · Accepted Answer

For many patients, major depressive disorder is a recurrent illness, as seen in this case. Recommendations for long-term maintenance antidepressant therapy should take the number of lifetime depressive episodes into account because prior history of episodes is the most consistently identified risk factor for future episodes. Patients with ≥2 episodes are candidates for maintenance antidepressant therapy (ie, continuing antidepressants for 1-3 years). Continuing treatment indefinitely can also be considered in some cases (eg, ≥3 lifetime depressive episodes) . Other indications for maintenance therapy include early age of onset, greater severity, suicidality, and the presence of severe, ongoing psychosocial stressors or persistent residual depressive symptoms. In contrast to patients with recurrent episodes, patients with a single episode of major depressive disorder should continue antidepressant treatment for a period of 6 months following response. If remission is sustained, the antidepressant can then be tapered and discontinued. (Choice A) Early age of onset (<20 years) is a risk factor for recurrence. (Choice B) Chronic depressive episodes (lasting >2 years) are an indication for maintenance therapy. However, this patient's current and prior depressive episodes lasted only a few months. (Choice C) A link between family history of anxiety disorders and the risk of recurrence of mood episodes has not been demonstrated. (Choice D) Patients who have an active comorbid psychiatric disorder or a history of childhood abuse are at an increased risk for depressive recurrence. However, this patient has no history of abuse, and his history of separation anxiety disorder is remote. (Choice F) There is no evidence that the presence of atypical depressive features (eg, hypersomnia, hyperphagia, mood reactivity) increases the risk of recurrence. Educational objective: Major depressive disorder is frequently recurrent. Long-term maintenance antidepressant therapy is indicated for patients with ≥2 major depressive episodes. References: Recurrence of major depressive disorder and its predictors in the general population: results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). (http://www.ncbi.nlm.nih.gov/pubmed/23111147) Predicting relapse after antidepressant withdrawal-a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/27786144)

A 42-Year-Old Man Comes to the Office Due to Persistent