Major Depressive Disorder

Answer: Next Steps After Treatment Failure in a Patient With MDD

Correct answer: C. Add L-methylfolate to her regimen at a dose of 15mg/d

Dose escalation of the sertraline may bring some marginal benefit, but with a medication-related adverse event already occurring, it is unlikely to result in the desired efficacy without negatively affecting adherence.1 If the patient does not desire CBT, insisting that she try it not only violates her autonomy, it may be less likely to be effective, owing to her preferences.2 Adding L-methylfolate is a suitable strategy, as patients with obesity often have a lower response to selective serotonin reuptake inhibitors (SSRIs),3 and L-methylfolate supplementation can increase efficacy.4 Combining two agents from the same class, particularly a class that has previously failed the patient, would not be preferred. Although exercise has shown benefits for patients with major depressive disorder in controlled trials,5 she has specifically requested pharmacotherapy, so the best solution is to pursue that treatment and encourage her to incorporate healthy choices into her lifestyle in addition to her medical therapy.

References:

  1. Jakubovski E, Varigonda AL, Freemantle N, Taylor MJ, Bloch MH. Systematic review and  meta-analysis: dose-response relationship of selective serotonin reuptake inhibitors in  major depressive disorder. Am J Psychiatry. 2016;173(2):174-83. doi:10.1176/appi.ajp.2015.15030331
  2. Moradveisi L, Huibers M, Renner F, Arntz A. The influence of patients' preference/attitude towards psychotherapy and antidepressant medication on the treatment of major depressive disorder. J Behav Ther Exp Psychiatry. 2014;45(1):170-7. doi:10.1016/j.jbtep.2013.10.003
  3. Kloiber S, Ising M, Reppermund S, Horstmann S, Dose T, Majer M, Zihl J, Pfister H, Unschuld PG, Holsboer F, Lucae S. Overweight and obesity affect treatment response in major depression. Biol Psychiatry. 2007;62(4):321-6. doi:10.1016/j.biopsych.2006.10.001
  4. Papakostas GI, Shelton RC, Zajecka JM, et al. L-methylfolate as adjunctive therapy for SSRI-resistant major depression: results of two randomized, double-blind, parallel-sequential trials. Am J Psychiatry. 2012;169(12):1267-74. doi:10.1176/appi.ajp.2012.11071114
  5. Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev. 2013;(9):CD004366. doi:10.1002/14651858.CD004366.pub6