What is the best course of action for a patient who stopped taking sertraline (selective serotonin reuptake inhibitor) due to side effects, is experiencing increasing depression, and has a relative with a severe and deteriorating medical condition?

Management of Patient Who Discontinued Sertraline

This patient should be restarted on sertraline 50 mg daily immediately, with close monitoring for worsening depression and suicidality, while addressing the abrupt discontinuation and providing psychosocial support for the situational stressor. 1

Immediate Actions Required

Restart Sertraline Without Delay

• Sertraline 50 mg daily is the optimal starting and therapeutic dose for most patients with depression, and this patient was previously doing well on 100 mg daily 2, 3
• The patient stopped sertraline approximately one week ago, which is within the timeframe where discontinuation syndrome can occur and depressive symptoms can worsen 4, 1
• Abrupt discontinuation of SSRIs can cause serious symptoms including anxiety, irritability, mood changes, and confusion—symptoms that may be contributing to his worsening depression 1

Address the Side Effect Concern

• The patient reports stopping due to side effects but cannot specify which ones, suggesting either:
  • Discontinuation syndrome symptoms being misattributed as side effects 4
  • Anxiety about potential side effects rather than actual experienced side effects 5
• Common sertraline side effects are typically mild, transient, and include nausea, diarrhea, and sexual dysfunction (primarily ejaculatory delay in males) 6, 7
• Sertraline has minimal anticholinergic activity, is essentially devoid of cardiovascular effects, and is well-tolerated compared to tricyclic antidepressants 7, 3

Critical Safety Monitoring

Suicidality Assessment and Monitoring

• The patient endorsed fleeting suicidal ideation without plan or intent—this requires intensive monitoring given the recent medication discontinuation 1
• The FDA black box warning mandates close observation for clinical worsening, suicidality, and unusual behavior changes, especially during initial treatment months or dose changes 1
• All patients on antidepressants should be monitored for emergence of agitation, irritability, unusual behavior changes, and suicidality, with families/caregivers alerted to report symptoms immediately 1
• Contact should occur within the first week after restarting medication (in-person or telephone) to review adherence, current status, and emergence of adverse events 5

Auditory Hallucinations Require Clarification

• The patient reports "sometimes" experiencing auditory hallucinations but refuses to elaborate on content, intensity, or frequency [@question context@]
• Before restarting an antidepressant, patients with depressive symptoms should be adequately screened for bipolar disorder risk, as treating a depressive episode with an antidepressant alone may precipitate a manic/mixed episode 1
• The presence of auditory hallucinations raises concern for:
  • Psychotic depression (which may require augmentation with antipsychotic)
  • Bipolar disorder with psychotic features
  • Primary psychotic disorder
• This requires urgent clarification before proceeding, though the patient's previous good response to sertraline alone suggests unipolar depression is most likely

Dosing Strategy

Restart at Previous Effective Dose

• Resume sertraline 50 mg daily for one week, then increase to 100 mg daily (the dose on which he was previously doing well) 1, 2
• The 50 mg starting dose is the usually effective therapeutic dose and optimal when considering both efficacy and tolerability 2
• For patients not showing adequate response, doses can be increased in 50 mg increments at weekly intervals to a maximum of 200 mg daily 1, 2

Duration of Treatment

• Treatment for a first episode of major depression should last at least four months; patients with recurrent depression may benefit from prolonged treatment 5
• Given this patient's worsening symptoms and situational stressor, continuation therapy beyond acute treatment is indicated 3

Addressing the Situational Stressor

Psychotherapy Engagement

• The patient declined teletherapy referral, stating he sees a therapist in another location but hasn't seen them for over a month [@question context@]
• Encourage immediate contact with his existing therapist—cognitive behavioral therapy (CBT) or interpersonal therapy (IPT) combined with medication is more effective than medication alone for moderate to severe depression 5
• The relative's deteriorating health (coughing blood) is a significant acute stressor requiring therapeutic support beyond medication

Care Coordination

• Obtain signed release of information to contact his treatment team and coordinate care [@question context@]
• The patient's reliance on his relative for medication pickup creates a practical barrier—address transportation alternatives or mail-order pharmacy options
• Ensure the relative attending future appointments can provide collateral information and support adherence

Common Pitfalls to Avoid

Do Not Switch Antidepressants Prematurely

• The patient was doing well on sertraline 100 mg before stopping—there is no indication to switch agents 5, 3
• All second-generation antidepressants are equally effective for treatment-naive patients; medication choice should be based on adverse effect profiles and patient preferences 5
• Switching would delay therapeutic benefit and introduce new side effect risks

Do Not Taper When Restarting

• Tapering is only necessary when discontinuing SSRIs to prevent withdrawal effects 4, 1
• When restarting after brief discontinuation, resume at therapeutic dose directly

Monitor for Serotonin Syndrome

• Although rare with sertraline monotherapy, be vigilant for symptoms including mental status changes, autonomic instability, neuromuscular symptoms, and GI disturbances 1
• Avoid combining with other serotonergic drugs (triptans, tramadol, other SSRIs, St. John's Wort) and MAOIs 1

Address the Medication Adherence Barrier

• The patient's dependence on his relative for medication pickup, combined with that relative's deteriorating health, creates a critical adherence risk
• Proactively establish alternative medication access before the current crisis worsens

Follow-Up Schedule

• Contact within 1 week of restarting sertraline to assess tolerability, adherence, and suicidality 5, 1
• In-person visit at 2 weeks to reassess depressive symptoms, auditory hallucinations, and suicidality
• Subsequent visits at 6 and 12 weeks to evaluate treatment response using PHQ-9 or similar standardized measure 8
• More frequent contact if suicidality worsens or new concerning symptoms emerge 1