Review Question - QID 214579

This patient who has not experienced any improvement in her symptoms after 2 weeks on a selective serotonin receptor inhibitor has not yet had an adequate treatment trial. Most patients do not experience improvements until 4-6 weeks after starting an antidepressant.

Selective serotonin reuptake inhibitors (SSRIs) are first-line medications in the treatment of major depressive disorder. Administration of these medications classically follows the rule of 6s, which is 6 weeks of initiation, 6 months of maintenance after the resolution of symptoms, and 6 weeks of washout. Importantly, many patients do not experience improvements in their symptoms until after 4-6 weeks of treatment, so medications should not be titrated or changed until after an adequate treatment trial period. The theoretical pathophysiological explanation for this extended initiation period is that SSRIs work partially due to plastic neuronal remodeling. After an adequate treatment trial, changes can include dosage titration, changing agents, or adding an augmenting agent.

Incorrect Answers:
Answer 1: Covert medication noncompliance could lead to medication failure; however, after only 2 weeks it is too early to conclude that the medication is not working. Furthermore, despite her husband's worries, there is no reason to believe that patient is lying about being compliant with her medications.

Answer 2: Factitious disorder can occur when patients consciously create symptoms in order to assume a patient role. These symptoms are often very difficult to treat because they are factitious in nature; however, there is no reason to believe this patient is not truly depressed.

Answer 4: Mood stabilizer should be used instead is incorrect because these medications are used in bipolar disorder. This patient was energetic and productive in the past, but there is no evidence that she ever met criteria for a manic episode. Distractibility, irresponsibility, grandiosity, flight of ideas, activity increase, pressured speech, and talkativeness are classic features of a manic episode.

Answer 5: Untreated hypothyroidism can lead to treatment-resistant depression; however, this patient denies corresponding somatic symptoms such as cold intolerance or weight gain. Furthermore, after only 2 weeks of treatment it is too early to conclude that the medication is not effective. A thyroid-stimulating hormone level should be obtained before initiating the treatment of depression.

Bullet Summary:
An adequate antidepressant treatment trial requires 4-6 weeks, and patients often do not experience symptom improvement until after several weeks.