A 33-Year-Old Man with an Unremarkable Medical History Comes to the Office

A 33-year-old man with an unremarkable medical history comes to the office due to fatigue and weight loss over the past 3 months.  He awakens at 4:00 AM each day and is unable to fall back asleep.  The patient also mentions that he had enjoyed golf and playing with his children but now has little interest in either activity.  Although he used to excel at work, he now has no motivation and "spaces out" at times.  Physical examination and laboratory studies, including TSH level, are normal.  The patient is diagnosed with major depressive disorder and prescribed fluoxetine.  Two weeks later, he calls to report that he is sleeping and eating better but is still depressed.  The patient is discouraged about his lack of improvement and says, "I don't feel like the medication is doing very much."  Which of the following is the most appropriate next step in pharmacological management?

A) Add aripiprazole to augment antidepressant response
B) Add bupropion to augment antidepressant response
C) Continue fluoxetine at present dose
D) Discontinue fluoxetine and begin a different selective serotonin reuptake inhibitor (SSRI)
E) Discontinue fluoxetine and begin a nonselective SRI
F) Increase dose of fluoxetine

Correct Answer:

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