What are the appropriate pharmacologic treatments to improve concentration and treat depression in a 42‑year‑old woman?

Treatment for Focus and Depression in a 42-Year-Old Woman

Start with either cognitive behavioral therapy (CBT) or a second-generation antidepressant (SSRI or bupropion), with bupropion being particularly advantageous when concentration difficulties are prominent, as it addresses both depressive symptoms and cognitive focus without causing sexual dysfunction. 1, 2, 3

Initial Treatment Selection

First-Line Options with Equal Efficacy

• CBT and second-generation antidepressants demonstrate equivalent effectiveness for major depressive disorder, with response rates, remission rates, and functional improvement showing no significant differences after 8-52 weeks of treatment 1, 2
• The choice between these equally effective options should be based on adverse effect profiles, cost, accessibility, and patient preference 1, 2

Bupropion as the Preferred Antidepressant for Focus Issues

• Bupropion specifically addresses concentration difficulties that accompany depression and is associated with significantly lower rates of sexual dysfunction compared to SSRIs (fluoxetine, sertraline, paroxetine) 1, 3
• The starting dose is 150 mg once daily, with increase to the usual target dose of 300 mg once daily after 4 days 3
• Bupropion showed superior reduction in depression severity compared to buspirone when used as augmentation therapy 1

Alternative SSRI Options

• If bupropion is contraindicated or not tolerated, sertraline, escitalopram, or fluoxetine are appropriate first-line alternatives 4, 5
• Among SSRIs, paroxetine has higher rates of sexual dysfunction than fluoxetine, fluvoxamine, or sertraline and should be avoided when sexual side effects are a concern 1

CBT as First-Line Alternative

• CBT has fewer adverse effects than medications, lower relapse rates upon treatment discontinuation, and no risk of medication-related side effects 1, 2
• CBT requires a trained therapist and is typically delivered over 8-16 weeks, focusing on identifying dysfunctional thought patterns, behavioral activation, and problem-solving strategies 2, 5
• CBT produces an enduring effect that reduces risk for relapse or recurrence long after treatment ends, which medications do not provide 6, 7

Treatment Implementation Algorithm

Acute Phase (6-12 weeks)

• Initiate either bupropion 150 mg daily (increase to 300 mg after 4 days) or CBT sessions 2, 3
• Monitor for response using standardized tools (PHQ-9 or Hamilton Depression Rating Scale), with response defined as ≥50% reduction in symptom severity 1, 2
• Assess improvement in target symptoms, including concentration difficulties, within 6 weeks of initiating therapy 1, 2

Continuation Phase (4-9 months)

• Continue treatment after achieving response to prevent relapse during the same depressive episode 1, 2
• Maintain therapeutic dose of medication or continue CBT sessions 2

Maintenance Phase (≥1 year if recurrent)

• For patients with multiple prior episodes, continue treatment for at least 1 year to prevent new episodes (recurrence) 1, 2

Critical Safety Monitoring

• Counsel patient and family about neuropsychiatric adverse effects, particularly monitoring for suicidal thoughts, mood changes, agitation, anxiety, and panic 2, 3
• Monitor blood pressure before initiating bupropion and periodically during treatment, as it can increase blood pressure 3
• Screen for bipolar disorder before starting antidepressants and monitor for activation of mania/hypomania 2, 3

Common Pitfalls to Avoid

• Do not start with combination therapy (CBT + antidepressant) for initial treatment, as it offers no advantage over monotherapy for moderate depression 2
• Do not use antidepressants if symptoms are subsyndromal or mild (fewer than 5 symptoms), as there is unlikely to be clinically important difference from placebo in this population 8
• Do not discontinue treatment prematurely—continue for minimum of 4-6 months after achieving response 2
• Do not fail to discuss sexual dysfunction when selecting among antidepressants, as this is a major cause of treatment discontinuation 1, 2

Bupropion-Specific Contraindications

• Absolute contraindications include seizure disorder, current or prior bulimia/anorexia nervosa, and abrupt discontinuation of alcohol or benzodiazepines 3
• Do not use with MAOIs or within 14 days of stopping an MAOI 3
• Reduce dose to 150 mg every other day in moderate to severe hepatic impairment 3

Second-Line Strategies if Initial Treatment Fails

• If initial antidepressant fails after adequate trial (6-12 weeks at therapeutic dose), switching to another second-generation antidepressant (sertraline, venlafaxine) shows similar response rates to augmentation strategies 1
• Augmenting citalopram with bupropion decreases depression severity more than augmentation with buspirone 1
• Switching to cognitive therapy shows similar outcomes to switching antidepressants 1