How to manage a 30-year-old man with major depressive disorder on SSRI 200mg daily experiencing anorexia, fatigue, and excessive sleep?

Management of Antidepressant-Induced Anorexia, Fatigue, and Hypersomnia in Major Depressive Disorder

For a 30-year-old man with major depressive disorder on SSRI 200mg daily experiencing anorexia, fatigue, and excessive sleep (12 hours nightly), the most effective approach is to switch to bupropion, starting at 150mg daily and titrating to 300mg daily after 4 days if tolerated.

Assessment of Current Symptoms

• The patient's symptoms of anorexia, fatigue, and hypersomnia are common side effects of SSRI therapy but can also represent residual depressive symptoms despite treatment 1
• Excessive sleepiness and fatigue are particularly difficult to treat and often persist as residual symptoms even among patients who have otherwise responded to standard antidepressants 1
• Sleep disturbances, including hypersomnia, are considered core symptoms of major depressive disorder rather than merely associated features 2

Treatment Approach

First-Line Option: Switch to Bupropion

• Bupropion is the preferred agent for this patient due to its activating properties and lower likelihood of causing fatigue, hypersomnia, or appetite suppression 3
• Initiate bupropion at 150mg once daily in the morning 3
• After 4 days, increase to the target dose of 300mg once daily in the morning if tolerated 3
• Bupropion should be swallowed whole (not crushed or chewed) and can be taken with or without food 3
• When switching from an SSRI to bupropion, a cross-taper approach is recommended to minimize discontinuation symptoms 3

Alternative Options if Bupropion is Contraindicated or Ineffective

1. Mirtazapine:

   • Starting dose of 7.5mg at bedtime, can be increased to 30mg at bedtime 4
   • Well-tolerated and promotes sleep, appetite, and weight gain 4
   • Particularly useful for patients with anorexia and sleep disturbances 4

2. Adjunctive Modafinil:

   • Consider as an augmentation strategy if switching antidepressants is not effective 5
   • Shown to improve excessive sleepiness and fatigue in patients with MDD who have residual symptoms despite SSRI therapy 5
   • Typical dose range is 100-400mg/day (median effective dose 300mg/day) 5

Monitoring and Follow-up

• Assess response after 2-4 weeks of treatment with the new medication 4
• Monitor for common side effects of bupropion including dry mouth, insomnia, dizziness, and anxiety 3
• Be alert for rare but serious adverse effects such as seizures (risk is dose-related) 3
• If the patient has a history of seizures, bupropion is contraindicated 3

Important Considerations and Precautions

• Avoid abrupt discontinuation of the current SSRI - taper over 10-14 days to limit withdrawal symptoms 4
• Monitor for activation of mania/hypomania when switching antidepressants, especially with bupropion 3
• Bupropion is contraindicated in patients with seizure disorders, current or prior diagnosis of bulimia or anorexia nervosa 3
• If the patient has moderate to severe hepatic impairment, the maximum bupropion dose should be 150mg every other day 3
• For patients with renal impairment, consider reducing the dose and/or frequency of bupropion 3

Treatment Duration

• Continue treatment for at least 16-24 weeks after symptom remission to prevent recurrence 6
• Periodically reassess the need for maintenance treatment and the appropriate dose 3

Remember that complete remission of MDD appears to depend on the relief of sleep disturbances and other core symptoms 2. Addressing the patient's anorexia, fatigue, and hypersomnia is crucial for improving overall functioning and quality of life.