Question

A female patient presents with depressed mood, loss of appetite and no interest in her surroundings, with associated insomnia. The onset of depression was preceded by a business loss, and soon afterwards she developed these symptoms, which have persisted for the past 1 year. Which of the following is true?

• A. No treatment is necessary as it is due to the business loss
• B. SSRIs are the most efficacious of the available drugs
• C. Start antidepressant drug treatment based on the side-effect profile
• D. Combination therapy with two antidepressant drugs

Hint:

If most antidepressants are equally effective, what should guide which one you pick?

Answer 1

The Correct Option is C

Step 1: Make the diagnosis.
Depressed mood, anhedonia, loss of appetite and insomnia persisting for one year fulfil criteria for major depressive disorder. A precipitating life event does not exclude the diagnosis; the duration and severity make this a full depressive episode, not transient grief or normal sadness.

Step 2: Reject option A.
A one-year depressive episode requires treatment; attributing it to the business loss and withholding therapy is incorrect.

Step 3: Reject option B.
SSRIs are first-line largely because of safety and tolerability, but no single class is the most efficacious for all patients; TCAs and others have comparable efficacy. Calling SSRIs the most efficacious is not accurate.

Step 4: Reject option D.
Initial management of a depressive episode is monotherapy. Combining two antidepressants at the outset is not standard and increases side effects.

Step 5: Select option C.
Because available antidepressants have broadly similar efficacy, the choice of agent is guided by the side-effect (and safety/tolerability) profile suited to the individual patient. Hence treatment should be started based on the side-effect profile.

Hence the answer is to start an antidepressant based on the side-effect profile.