From the Research
The most appropriate next step for this 53-year-old woman with seasonal affective disorder (SAD) who has not responded to phototherapy would be to initiate antidepressant medication, specifically fluoxetine therapy. This recommendation is based on the most recent and highest quality study available, which suggests that fluoxetine is a viable treatment option for SAD, with some evidence showing its efficacy in achieving clinical response and remission 1.
Key Considerations
- The patient's symptoms, including persistent fatigue, feelings of worthlessness, loss of interest in activities, and unintentional weight gain, are consistent with SAD.
- The patient has not responded to phototherapy, which is a common first-line treatment for SAD.
- Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has been shown to be effective in treating SAD, with a favorable side effect profile compared to other antidepressants.
Treatment Approach
- Fluoxetine (Prozac) 20 mg daily would be a good initial choice, with the option to increase the dose after 4-6 weeks if response is inadequate.
- Treatment should begin before the onset of seasonal symptoms and continue through the winter months until spring, typically for 4-6 months.
- If the patient does not respond to the initial SSRI after an adequate trial (6-8 weeks at therapeutic dose), switching to another SSRI, adding cognitive behavioral therapy specifically tailored for SAD, or considering bupropion XL (another FDA-approved option for SAD prevention) at 150-300 mg daily would be reasonable next steps.
Rationale
- The mechanism of SSRIs, including fluoxetine, likely involves increasing serotonin availability in the brain, which helps regulate mood and may compensate for the decreased serotonin activity associated with reduced sunlight exposure during winter months.
- While other treatment options, such as electroconvulsive therapy, lorazepam therapy, and transcranial magnetic stimulation, may be considered in certain cases, they are not typically recommended as first-line treatments for SAD.
- The evidence from studies, including those published in 2018 2 and 2015 3, supports the use of fluoxetine as a treatment option for SAD, although more research is needed to fully understand its efficacy and safety in this population.