What is the first‑line treatment for a 60‑year‑old woman in remission after a first episode of psychosis who now has a major depressive episode?

First-Line Treatment for Major Depression Following First-Episode Psychosis in Remission

For a 60-year-old woman in remission from first-episode psychosis who now presents with major depression, initiate a second-generation antidepressant (SSRI) while continuing her antipsychotic medication, with sertraline being the preferred agent due to its favorable safety profile, minimal drug interactions, and established efficacy in this age group. 1, 2

Rationale for Antidepressant Selection

Why SSRIs Are First-Line

• Second-generation antidepressants (SSRIs, SNRIs) should be selected based on adverse effect profiles, cost, and patient preferences when treating major depression 1
• In elderly patients (≥60 years), consensus guidelines recommend a "start low, go slow" approach, with preferred medications including sertraline, citalopram, escitalopram, mirtazapine, and venlafaxine 1
• Sertraline specifically has demonstrated effectiveness in elderly patients with major depressive disorder (ages ≥60 years) at doses of 50-200 mg/day 3

Why Sertraline Is Optimal in This Case

• Sertraline has a low potential for drug interactions at the cytochrome P450 enzyme level, which is critical when co-prescribed with antipsychotic medications 3
• No dosage adjustments are warranted for elderly patients based solely on age 3
• Sertraline is FDA-approved for major depressive disorder and has well-established efficacy in maintaining antidepressant response for up to 44 weeks 2
• The drug is generally well tolerated in elderly patients, lacking the marked anticholinergic effects of tricyclic antidepressants 3

Treatment Algorithm

Initial Dosing

• Start sertraline at 50 mg daily 2, 3
• This starting dose is appropriate for both general adult and elderly populations 2
• The dose can be increased to 100 mg/day after 1 week if needed, with a maximum of 200 mg/day 2, 4

Monitoring Schedule

• Assess patient status, therapeutic response, and adverse effects within 1-2 weeks of initiation 1
• Continue regular assessments throughout the acute treatment phase 1
• If no adequate response occurs within 6-8 weeks, modify treatment 1

Duration of Treatment

• Continue treatment for 4-9 months after achieving satisfactory response for a first episode of major depression 1
• Given this patient's history of psychosis, consider longer duration therapy, as patients with recurrent psychiatric episodes may benefit from prolonged treatment 1

Critical Considerations for This Population

Continue Antipsychotic Medication

• Do not discontinue the antipsychotic even though the patient is in remission from psychosis 1
• Relapses are common during the first few years after onset of a psychotic disorder, with vulnerability to relapse persisting in approximately 80% of patients 1
• Continuity of care with consistent treating clinicians for at least 18 months is essential 1

Monitor for Depression-Specific Risks

• Depression, suicide risk, substance misuse, and social anxiety should be actively identified and treated in patients recovering from first-episode psychosis 1
• Depression affects more than 40% of people following first-episode psychosis and adds to individual burden and poor outcomes 5

Evidence Regarding Monotherapy vs. Combination Treatment

Antidepressant Alone Is Insufficient for Psychotic Depression

• If this patient were experiencing concurrent psychotic and depressive symptoms (psychotic depression), sertraline monotherapy would be inadequate 4
• Psychotic depression responds more poorly to sertraline alone compared to depression without psychosis, with significantly lower remission rates (p=0.001) 4
• Conventional pharmacotherapy for active psychotic depression consists of tricyclic antidepressants combined with antipsychotics, or electroconvulsive therapy 6

But This Patient Is Different

• This patient is in remission from psychosis, meaning she currently has major depression without active psychotic features [@question context@]
• Therefore, standard antidepressant treatment is appropriate while maintaining antipsychotic coverage for relapse prevention 1

Common Adverse Effects to Monitor

• The most frequently reported adverse events with sertraline in elderly patients include: dry mouth, headache, diarrhea, nausea, insomnia, somnolence, constipation, dizziness, sweating, and taste abnormalities 3
• Nausea and vomiting are the most common reasons for discontinuation 1
• About two-thirds of patients receiving second-generation antidepressants experience at least one adverse effect during treatment 1

Common Pitfalls to Avoid

Don't Stop the Antipsychotic

• Abrupt discontinuation of antipsychotics after acute symptom resolution increases relapse risk 1, 7
• Maintain vigilance for early signs of psychotic relapse while providing space for recovery 1

Don't Wait Too Long to Modify Treatment

• If inadequate response occurs by 6-8 weeks, switching or augmenting antidepressant therapy is indicated 1
• Continuing ineffective treatment delays recovery and worsens outcomes 1

Don't Overlook Drug Interactions

• While sertraline has low interaction potential, always verify compatibility with the specific antipsychotic the patient is taking 3
• Pharmacokinetic interactions are likely in combination treatment and may mimic the underlying condition 6