A 53-Year-Old Man Comes to the Office Due to Persistent

A 53-year-old man comes to the office due to persistent fatigue.  The patient started a therapeutic dose of fluoxetine 2 months ago after being diagnosed with major depressive disorder.  He says, "Since I last saw you, I still feel like I'm dragging pretty much every day and have to force myself to go to work in the mornings.  I haven't even wanted to have sex with my wife.  That's been going on for almost a month, and it's really bothering me."  The patient works as a high school English teacher and notes, "It takes me so long to grade my students' essays because I am so easily distracted."  Medical history includes hypertension treated with enalapril.  He had a 4-kg (9-lb) weight gain over the past 2 months.  Blood pressure is 130/84 mm Hg and pulse is 76/min.  Physical examination shows no abnormalities.  The patient appears depressed and speaks softly throughout the interview.  Which of the following is the most appropriate next step in pharmacotherapy?

A) Continue fluoxetine and add aripiprazole
B) Continue fluoxetine and add methylphenidate
C) Discontinue fluoxetine and begin bupropion
D) Discontinue fluoxetine and begin venlafaxine
E) Increase dosage of fluoxetine
F) Increase dosage of fluoxetine and add sildenafil

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