Major depressive disorder (MDD) can be challenging to manage, especially when patients show only a partial response to initial treatment. Developing a treatment plan to move forward requires careful consideration of medication adjustments and a personalized approach that takes patient preferences into account.
In response to this post, practitioners on Healthcasts weighed options for a patient with a partial SSRI response, sharing strategies for dose optimization, ways to involve the patient in treatment decisions, and more.
How would you treat this patient? Log in or sign up to leave a comment and see the consensus.
Patient Profile:
• 30-year-old female
• Diagnosed with Major Depressive Disorder (MDD) 2 years ago.
Current Status:
• Current episode began approximately 7 months ago.
• Patient is experiencing persistent sadness and low mood nearly every day, marked loss of interest in almost all activities, significant weight loss, insomnia, fatigue, and inability to concentrate.
• No history of seizures or substance use disorder.
Current Treatments:
• Achieving a partial response with sertraline 100 mg daily.
• Trazodone 50 mg at night for sleep.
• Patient has completed cognitive behavioral therapy alongside pharmaceutical intervention; showed some benefit, but did not fully alleviate symptoms.
1. What treatment would you recommend for this patient? Why?
2. In newly diagnosed patients with MDD presenting similarly to this patient, what is your standard first-line treatment?
Key takeaways on major depressive disorder treatment strategies:
Family Practice
"1. I would do GeneSight testing for this patient. I have found this incredibly helpful for patients who aren’t responding to treatments or who have failed multiple medications. It’s a cotton swab in the mouth that analyzes any DNA variances that may affect how different mental health medications are metabolized. Insurance covers it pretty well, too! Swab the mouth and mail it back in the kit. Results are emailed to the provider within a couple of weeks.
2. I usually do sertraline or Wellbutrin."
Nurse Practitioners
"1. You could add Wellbutrin if taking 2 medications daily is agreeable with the patient. The other choice would be to increase the dose of Sertraline. I would offer education on both and let the patient help decide what would be best for her.
2. I tend to start with Sertraline or similar SSRI's especially for females. Often in males, I start with Prozac."
Psychiatry
"1. Optimize sertraline dose to 150-200 mg if tolerated or augmentation with bupropion (target fatigue and anhedonia) or Abilify (if residual mood symptoms predominate). If inadequate benefit, switch to SNRI.
2. SSRI or SNRI combined with psychotherapy. I reassess response within 4-6 weeks before considering dose escalation or augmentation."
Psychiatry
"1. At this point, initially, I will quickly titrate sertraline since there is a partial response, and if there is no further improvement at 200 mg a day, I would consider switching to an SNRI.
2. I would still consider starting an SSRI initially, but quickly switching to an SNRI if there is no Adequate response."
Family Practice
"1. I would first recommend increasing the dose of sertraline. She’s had a partial response; this may be improved by just increasing the dose. She’s also of child-bearing age, and sertraline is one of the safer antidepressants to be on. The other option would be keeping the same dose and adding in something such as Wellbutrin. Could consider seasonal affective disorder affecting mood.
2. First line treatment for me, as always, is SSRI and CBT, as well as encouraging daily exercise. Can also add in vitamin B and vitamin D, as there could be a deficiency, especially in vitamin D."
What advice would you provide on major depressive disorder treatment strategies? Review the full case on Healthcasts and leave a comment to help your peers.