What is the best course of action for a patient with depression and anxiety, currently on sertraline (Selective Serotonin Reuptake Inhibitor), who reports diminishing efficacy, potential Attention Deficit Hyperactivity Disorder (ADHD) symptoms, and significant anxiety, despite ongoing therapy?

Management Plan for Patient with Depression, Anxiety, and Suspected ADHD

The best course of action for this patient is to refer her to a psychiatrist for evaluation of possible ADHD while simultaneously switching from sertraline to another antidepressant or augmenting the current regimen to address her diminishing response to sertraline. 1, 2

Assessment of Current Situation

• Patient has been on sertraline for 3 years for depression and anxiety
• Reports diminishing efficacy, especially during stressful periods
• Current symptoms include:
  • Low energy and reduced motivation
  • Feeling overwhelmed by academic work
  • Significant procrastination and difficulty initiating tasks
  • Daily anxiety worsened by academic struggles
  • Irritability and inability to relax
• Patient suspects ADHD as contributing to her depression symptoms
• No history of mania, psychosis, suicidal ideation, or self-harm

Treatment Recommendations

1. Psychiatric Referral for ADHD Evaluation

• Refer to psychiatrist for comprehensive ADHD assessment 2
• Symptoms suggesting possible ADHD:
  • Difficulty initiating tasks
  • Procrastination
  • Feeling overwhelmed by academic work
  • These symptoms may be worsening her depression and anxiety

2. Antidepressant Management Options

Option A: Switch to a Different Antidepressant

• Evidence shows that when initial SSRI therapy fails, approximately 25% of patients become symptom-free after switching medications 1
• Consider switching to:
  • Bupropion - beneficial for both depression and potential ADHD symptoms 3, 4
  • Venlafaxine - may be more effective for anxiety symptoms with depression 1

Option B: Augmentation Strategy

• If partial response to sertraline:
  • Consider adding bupropion to sertraline 1
  • This combination may address both depression and ADHD-like symptoms 4

3. If ADHD is Confirmed by Psychiatrist

• Consider combination therapy:
  • Continue antidepressant therapy (either sertraline or new agent)
  • Add ADHD-specific medication such as atomoxetine or methylphenidate 2, 5
  • Recent evidence shows no significant increase in adverse events with SSRI plus methylphenidate combination 5

Rationale for Recommendations

1. Addressing treatment-resistant depression: Studies show that 38% of patients do not achieve response and 54% do not achieve remission with initial SSRI treatment 1. This patient's diminishing response after 3 years suggests the need for a treatment change.

2. Addressing possible ADHD: The patient's symptoms of procrastination, difficulty initiating tasks, and feeling overwhelmed suggest possible ADHD, which may be contributing to or exacerbating her depression and anxiety 2, 3.

3. Evidence for combined approach: Research indicates that when ADHD and depression coexist, treating both conditions concurrently leads to better outcomes 4, 5.

Common Pitfalls to Avoid

• Dismissing ADHD concerns: Adult ADHD is often overlooked, especially in women, and can present as depression and anxiety when untreated.

• Continuing ineffective treatment: Continuing sertraline alone when efficacy is diminishing may lead to worsening symptoms and functional decline.

• Treating only one condition: Addressing only depression without evaluating for ADHD may result in incomplete symptom resolution.

• Starting stimulants without psychiatric evaluation: Initiating ADHD medication without proper diagnosis could worsen anxiety symptoms if ADHD is not present.

• Abrupt discontinuation of sertraline: If switching medications, taper sertraline gradually to avoid discontinuation syndrome.

Monitoring Plan

• Follow up within 2-4 weeks after any medication change
• Monitor for:
  • Improvement in depressive symptoms
  • Changes in anxiety levels
  • Side effects of new medications
  • Improvement in task initiation and completion
• Maintain communication with therapist regarding treatment changes