A 44-year-old man comes to the office due to depression, loss of interest, impaired concentration, fatigue, and poor sleep. The patient is not suicidal and has no psychotic symptoms. He has no psychiatric history. Physical examination and laboratory evaluation are unremarkable. Major depressive disorder is diagnosed, and he is treated with 50 mg of sertraline. After a month of antidepressant treatment, the patient reports improvement in his energy level and sleep, although he continues to struggle with some sadness and low motivation. The dose of sertraline is increased to 100 mg. At his 2-month follow-up, the patient has no depressive symptoms and says, "I feel like I'm totally back to normal. Work is going well and I'm really enjoying life again." He has no adverse effects from the sertraline. The patient asks when he can stop taking the medication. Which of the following is the most appropriate response?
This patient has achieved remission after acute-phase treatment with sertraline. To decrease the risk of depressive relapse, multiple evidence-based treatment guidelines recommend continuing antidepressant treatment for an additional 6 months in patients with remitted single-episode, unipolar major depression (referred to as continuation-phase treatment). The dose should be maintained at the level at which remission was achieved and should not be reduced (ie, the dose that gets the patient well keeps the patient well) (Choice A). If complete remission is maintained at the end of the continuation phase, the antidepressant can then be tapered gradually and discontinued.
Maintenance-phase treatment is defined as continuing antidepressant medication past the initial continuation-phase treatment. Maintenance for 1-3 years is appropriate for patients with a high risk of recurrence (eg, ≥2 episodes, persistent residual depressive symptoms) (Choice B). Patients with a history of highly recurrent major depressive disorder (≥3 lifetime depressive episodes), chronic episodes (≥2 years), strong family history, or severe episodes (eg, suicide attempt) should continue maintenance treatment indefinitely (Choice E).
(Choices D and F) Tapering and discontinuing sertraline now or in 6 weeks would increase the patient's risk for relapse. Sertraline should be maintained for an additional 6 months to achieve sustained remission.
Educational objective:
Patients with a single episode of major depressive disorder should continue antidepressants for an additional 6 months following acute response to reduce the risk of relapse. Patients with recurrent, chronic, or severe episodes should be considered for maintenance treatment (1-3 years or indefinitely).