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Add lithium
0%
0/7
Continue current medication
86%
6/7
Increase dose of current medication
14%
1/7
Switch to bupropion
Switch to paroxetine
Select Answer to see Preferred Response
This patient is presenting with depression given her sleep disorder, guilt, appetite changes, depressed mood, and fatigue. First-line pharmacotherapy for major depressive disorder (MDD) is treatment with an SSRI which should be continued for at least 6-8 weeks prior to assessing for treatment success/failure. Depression presents with 5 of the SIGE CAPS criteria: sleep changes, interest loss, guilt, energy changes, concentration trouble, appetite changes, psychomotor changes, and suicidal ideation. SSRIs are the first-line therapy for MDD as they have fewer side effects overall when compared to other antidepressants. Most commonly, patients experience weight gain, anxiety, agitation, insomnia, GI distress, and sexual dysfunction (anorgasmia). Before changing a patient's medication, they should try an SSRI for at least 6-8 weeks given this is how long it could take for the medication to take effect. If a patient fails therapy on an SSRI, another SSRI should be tried (also for 6-8 weeks). Incorrect Answers: Answer 1: Add lithium may be appropriate as an adjunct agent in addition to thyroxine both of which may improve the response to SSRIs (however this is not a typical first- or second-line modification). It would be a potential option in treatment after the patient failed her current SSRI including duration, dosing, and alternative agents. Prior to diagnosing depression it is important to always check a TSH level and treat any underlying hypothyroidism. Answer 3: Increase dose of current medication could be appropriate if after a 6-8 week period, the patient's symptoms have not improved. Answer 4: Switch to bupropion would be appropriate if this patient were trying to quit smoking, or could not tolerate the sexual side effects of an SSRI. Bupropion can lower the seizure threshold. Answer 5: Switch to paroxetine may be appropriate if the patient does not respond to his current SSRI after 6-8 weeks of therapy. Bullet Summary: SSRIs are the first line treatment for depression and should be continued for 4-8 weeks before changing therapy.
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