What medication should be started for an obese patient with a history of suicide attempt, unintentional weight gain, symptoms of depression, and postpartum depression: a monoamine (Monoamine) oxidase inhibitor, an SNRI (Serotonin-Norepinephrine Reuptake Inhibitor), or a tricyclic antidepressant?

Medication Selection for Obese Patient with Depression and Suicidal History

Bupropion is the most appropriate first-line medication choice for an obese patient with depression, postpartum depression, history of suicide attempt, and unintentional weight gain. 1, 2

Rationale for Medication Selection

Weight Considerations

• Bupropion is associated with weight loss effects, making it ideal for patients with obesity and unintentional weight gain 2, 1
• Most antidepressants cause weight gain, but bupropion consistently demonstrates weight-loss properties 3
• Other antidepressants have varying effects on weight:
  • Mirtazapine, paroxetine, and tricyclic antidepressants (TCAs) are associated with significant weight gain 3, 4
  • SNRIs have mixed effects but may cause weight gain in some patients 1

Suicide Risk Assessment

• Patient has history of suicide attempt, requiring careful medication selection
• Bupropion has a lower risk of fatal overdose compared to TCAs 5
• TCAs are associated with higher rates of death in overdose due to cardiotoxicity 5
• MAOIs and TCAs may have higher overdose proclivity rates 6

Efficacy for Depression

• Bupropion has comparable efficacy to other second-generation antidepressants for treating major depressive disorder 1
• Evidence does not support clinically significant differences in efficacy among SSRIs, SNRIs, and other second-generation antidepressants 1
• The American College of Physicians guidelines indicate that bupropion is effective for depression with a mean weight loss of 2.8 kg at 6-12 months 1

Contraindications and Considerations

Avoid These Options

1. Tricyclic Antidepressants (TCAs):

   • Associated with significant weight gain 4
   • Higher risk of fatal overdose, particularly concerning with suicide history 5
   • Amitriptyline specifically shows high risk of weight gain 3

2. Monoamine Oxidase Inhibitors (MAOIs):

   • Higher risk of overdose compared to newer antidepressants 6
   • Complex dietary restrictions and drug interactions
   • Not first-line for depression with suicide risk

3. Paroxetine and Mirtazapine:

   • Associated with higher weight gain than other antidepressants 1, 3
   • Paroxetine has higher rates of sexual dysfunction 1

Monitoring and Follow-up

• Regular monitoring of:

  • Weight and BMI
  • Depressive symptoms using validated scales
  • Suicidal ideation
  • Medication side effects
  • Blood pressure (bupropion may increase BP in some patients)

• Bupropion should be initiated at a lower dose and titrated gradually

• Avoid in patients with seizure disorders (bupropion has a slightly increased seizure risk)

• Combine with psychotherapy for optimal outcomes

Alternative Options

If bupropion is contraindicated or not tolerated:

• Fluoxetine may cause short-term weight loss but effect diminishes over time 3
• SNRIs like venlafaxine or duloxetine may be considered but monitor for blood pressure changes 1
• Aripiprazole has lower weight gain potential if an antipsychotic is needed for augmentation 7

Remember that medication should be combined with lifestyle interventions including diet and exercise for optimal management of both depression and obesity 1.