Restart Sertraline for Recurrent Depression with Anxiety
Restart sertraline at 50 mg daily as the first-line treatment for this patient with recurrent depression and anxiety, rather than switching to buspirone, which is not an antidepressant and lacks efficacy as monotherapy for major depression. 1, 2, 3
Rationale for Restarting Sertraline
Prior response to sertraline is the strongest predictor of future response. Since this patient previously took sertraline (implying it was effective enough to warrant continuation before discontinuation), restarting the same medication capitalizes on established efficacy in this individual. 1, 4
Sertraline is FDA-approved and guideline-recommended as first-line treatment for both major depressive disorder and multiple anxiety disorders (panic disorder, social anxiety disorder, generalized anxiety disorder, PTSD), making it ideal for comorbid depression and anxiety. 2, 3, 4
The American College of Physicians and American Family Physician guidelines establish sertraline as a preferred first-line SSRI due to its optimal balance of efficacy, safety, and tolerability across depression and anxiety disorders. 1, 2
Discontinuation of effective antidepressant treatment commonly leads to relapse—studies show 26-52% of patients relapse when sertraline is discontinued, compared to only 5-16% who continue medication. 1
Why Buspirone is NOT the Answer
Buspirone is not an antidepressant and should never be used as monotherapy for major depression. 5, 6
Buspirone is FDA-approved only as an anxiolytic for generalized anxiety disorder, not for depression. 3
Research evidence shows buspirone augmentation of SSRIs in treatment-resistant depression produces weak or minimal antidepressant response, with one study reporting "no case with complete recovery" and concluding they "cannot recommend buspirone augmentation in severely ill depressives." 5
While one small study showed 59% response when buspirone was added to ongoing SSRI treatment in SSRI non-responders, this applies only to augmentation strategy after SSRI failure—not as initial monotherapy. 7
Critical FDA warning: Combining buspirone with sertraline increases serotonin syndrome risk, requiring careful monitoring if ever used together. 3
Practical Prescribing Strategy
Start sertraline 50 mg once daily. If the patient is particularly anxious or had initial activation symptoms previously, consider starting with 25 mg daily for 3-7 days as a "test dose" before increasing to 50 mg. 2
Increase dose in 50 mg increments at 1-2 week intervals if response is inadequate, up to maximum 200 mg daily. 2
Allow 6-8 weeks for adequate trial, including at least 2 weeks at maximum tolerated dose, before concluding treatment failure. 2
Assess treatment response at 4 weeks and 8 weeks using standardized measures, and monitor for treatment-emergent suicidality especially in the first 1-2 weeks after initiation or dose changes. 2, 3
Treatment Duration to Prevent Future Relapse
Continue sertraline for minimum 4-9 months after satisfactory response for recurrent depression. Since this patient has already had at least two episodes (initial episode plus current recurrence), consider longer duration of ≥1 year or indefinite maintenance therapy. 1, 2
After a first episode, recurrence probability is 50%; after two episodes it increases to 70%; after three episodes it reaches 90%. 1
Meta-analysis of 31 trials demonstrates that continued antidepressant treatment after remission significantly protects against relapse and recurrence. 1
Critical Safety Monitoring
Monitor closely for suicidality, particularly during the first 1-2 months. All SSRIs including sertraline carry FDA black box warnings for increased suicidal thinking and behavior, especially in patients under age 24, with 14 additional cases per 1000 patients treated compared to placebo. 2, 3
Families and caregivers should be instructed to monitor for emergence of agitation, irritability, unusual behavior changes, and suicidality, and report immediately. 3
Never discontinue sertraline abruptly—taper gradually when stopping to minimize discontinuation syndrome (dizziness, nausea, sensory disturbances, paresthesias). 2, 3
Screen for bipolar disorder before initiating treatment, as treating bipolar depression with an antidepressant alone may precipitate manic/mixed episodes. Obtain detailed psychiatric history including family history of bipolar disorder. 3
Common Pitfalls to Avoid
Don't switch medications prematurely. Partial response at 4 weeks warrants continued treatment and dose optimization, not switching. Full response may take 6-8 weeks. 2
Don't use buspirone as monotherapy for depression. It is not an antidepressant and lacks efficacy for major depressive disorder. 5, 6
Don't underdose. Many patients require 100-200 mg daily for optimal response. Confirm medication adherence before each dose increase. 2
Don't forget to address why the patient discontinued sertraline initially. If discontinuation was due to side effects rather than remission, address tolerability concerns and consider strategies to minimize adverse effects. 3