Postpartum depression US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Postpartum depression. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Postpartum depression US Medical PG Question 1: A 26-year-old woman is brought to the emergency department by her husband due to her disturbing behavior over the past 24 hours. Her husband says that he has noticed his wife talking to herself and staying in a corner of a room throughout the day without eating or drinking anything. She gave birth to their son 2 weeks ago but has not seen or even acknowledged her baby’s presence ever since he was born. He says that he didn’t think much of it because she seemed overwhelmed during her pregnancy and he considered that she was probably unable to cope with being a new mother; however, last night, he says, his wife told him that their child was the son of the devil and they ought to get rid of him as soon as possible. Which of the following describes this patient’s abnormal reaction to her child?
- A. Brief psychotic disorder
- B. Schizoaffective disorder
- C. Postpartum psychosis (Correct Answer)
- D. Major depressive disorder
- E. Postpartum blues
Postpartum depression Explanation: **Postpartum psychosis**
- This patient exhibits **psychotic symptoms** (delusions about the child, hallucinations like talking to herself) and **severe disorganization** (staying in a corner, not eating/drinking, neglecting her baby) within two weeks postpartum.
- This severe and acute onset of psychosis in the **postpartum period** is characteristic of postpartum psychosis, which is a medical emergency requiring immediate intervention.
*Brief psychotic disorder*
- While it involves psychotic symptoms of acute onset and short duration (less than one month), this diagnosis typically applies when symptoms are not directly attributable to a specific precipitating factor like childbirth.
- The clear temporal association with childbirth in this case makes postpartum psychosis a more specific and accurate diagnosis.
*Schizoaffective disorder*
- This disorder typically involves a combination of **mood symptoms** (depressive or manic) and **psychotic symptoms**, where psychotic symptoms are present for at least two weeks in the absence of a major mood episode.
- The sudden onset and direct link to the postpartum period distinguish this case from schizoaffective disorder, which usually has a more chronic or episodic course.
*Major depressive disorder*
- Although the patient shows signs of severe withdrawal and neglect, the presence of **frank psychotic symptoms** (delusions about the child being the "son of the devil") goes beyond the typical presentation of major depressive disorder, even with psychotic features.
- While depression can coexist, the predominant and acute psychotic features point more directly to postpartum psychosis.
*Postpartum blues*
- Postpartum blues are **mild and transient mood disturbances** (tearfulness, irritability, anxiety) occurring in the first few days to two weeks postpartum, typically resolving on their own.
- The patient's symptoms are far more severe, involving **psychotic delusions and severe functional impairment**, making postpartum blues an inadequate diagnosis.
Postpartum depression US Medical PG Question 2: A 27-year-old woman visits a psychiatrist expressing her feelings of sadness which are present on most days of the week. She says that she has been feeling this way for about 2 to 3 years. During her first pregnancy 3 years ago, the fetus died in utero, and the pregnancy was terminated at 21 weeks. Ever since then, she hasn’t been able to sleep well at night and has difficulty concentrating on her tasks most of the time. However, for the past month, she has found it more difficult to cope. She says she has no will to have another child as she still feels guilty and responsible for the previous pregnancy. Over the past few days, she has completely lost her appetite and only eats once or twice a day. She doesn’t recall a single day in the last 3 years where she has not felt this way. The patient denies any past or current smoking, alcohol, or recreational drug use. Which of the following is the most likely diagnosis in this patient?
- A. Persistent depressive disorder (Correct Answer)
- B. Bipolar disorder
- C. Schizoaffective disorder
- D. Cyclothymia
- E. Major depressive disorder
Postpartum depression Explanation: ***Persistent depressive disorder***
- The patient exhibits classic symptoms of **persistent depressive disorder (dysthymia)**: chronic depressed mood for **at least two years**, accompanied by other depressive symptoms like **insomnia**, **difficulty concentrating**, and changes in appetite.
- The duration of her symptoms (2-3 years) and the consistent feeling of sadness support this diagnosis, fitting the diagnostic criteria for **dysthymia**.
*Bipolar disorder*
- Bipolar disorder involves distinct episodes of **mania or hypomania** alternating with depressive episodes.
- The patient's history does not indicate any periods of elevated mood, increased energy, or decreased need for sleep, which are characteristic of **bipolar disorder**.
*Schizoaffective disorder*
- Schizoaffective disorder is characterized by a combination of **mood symptoms** (like depression or mania) and **psychotic symptoms** (like delusions or hallucinations) occurring simultaneously or in distinct episodes.
- This patient presents with no evidence of **psychotic symptoms** such as hallucinations or delusions.
*Cyclothymia*
- Cyclothymia is a milder, chronic form of **bipolar disorder** involving numerous periods of **hypomanic symptoms** and numerous periods of **depressive symptoms** for at least two years.
- The patient's presentation lacks any history of **hypomanic episodes**, making cyclothymia an unlikely diagnosis.
*Major depressive disorder*
- While the patient is experiencing a **major depressive episode** currently (as suggested by increased severity in the last month and complete loss of appetite), the underlying chronic nature of her symptoms (2-3 years) and the fact that she has not been symptom-free for more than two months indicate **persistent depressive disorder**.
- A diagnosis of **major depressive disorder** would typically be given if the symptoms were acute (less than 2 years) and severe, without the chronic, pervasive depressive state described.
Postpartum depression US Medical PG Question 3: A 28-year-old woman is brought into the clinic by her husband with concerns that she might be depressed. She delivered a healthy newborn a week and a half ago without any complications. Since then, she has been having trouble sleeping, eating poorly, and has stopped playing with the baby. The patient says she feels like she is drained all the time and feels guilty for not doing more for the baby. Which of the following is the best course of treatment for this patient?
- A. Reassurance
- B. Fluoxetine (Correct Answer)
- C. Risperidone
- D. Amitriptyline
- E. No treatment
Postpartum depression Explanation: ***Fluoxetine***
- This patient's symptoms (trouble sleeping, poor appetite, guilt, and anhedonia towards the baby) occurring 10 days postpartum are highly suggestive of **postpartum depression**. **SSRIs** like fluoxetine are first-line pharmacological treatments for this condition.
- Fluoxetine is a **selective serotonin reuptake inhibitor (SSRI)** that helps regulate mood by increasing serotonin levels in the brain. It is generally considered safe during breastfeeding, with a relatively low infant exposure compared to other antidepressants.
*Reassurance*
- Reassurance alone may be appropriate for **postpartum blues**, which are milder and self-limiting, typically resolving within two weeks.
- This patient's symptoms are more severe and persistent, lasting beyond typical postpartum blues and significantly impacting her functioning, indicating a need for more substantial intervention.
*Risperidone*
- Risperidone is an **atypical antipsychotic** primarily used to treat conditions like schizophrenia or bipolar disorder, or as an adjunct for severe refractory depression with psychotic features.
- There is no indication of psychosis in this patient's presentation, and the use of an antipsychotic would be disproportionate and carry unnecessary side effects.
*Amitriptyline*
- Amitriptyline is a **tricyclic antidepressant (TCA)**. While effective for depression, TCAs are generally not first-line due to a less favorable side effect profile (e.g., anticholinergic effects, cardiac conductivity issues) compared to SSRIs.
- SSRIs like fluoxetine are preferred for initial treatment of postpartum depression due to their better tolerability and safety profile.
*No treatment*
- This patient exhibits clear symptoms of **postpartum depression**, which is a serious condition that can worsen without intervention and impact both the mother's and infant's well-being.
- Untreated depression can lead to significant functional impairment, chronic suffering, and in severe cases, harm to oneself or the baby.
Postpartum depression US Medical PG Question 4: A 25-year-old woman comes to the physician because of sadness that started 3 weeks after her daughter was born. Her daughter is now 9 months old and usually sleeps through the night, but the patient still has difficulty staying asleep. She has not returned to work since the birth. She is easily distracted from normal daily tasks. She used to enjoy cooking, but only orders delivery or take-out now. She says that she always feels too exhausted to do so and does not feel hungry much anyway. The pregnancy of the patient's child was complicated by gestational diabetes. The child was born at 36-weeks' gestation and has had no medical issues. The patient has no contact with the child's father. She is not sexually active. She does not smoke, drink alcohol, or use illicit drugs. She is 157 cm (5 ft 1 in) tall and weighs 47 kg (105 lb); BMI is 20 kg/m2. Vital signs are within normal limits. She is alert and cooperative but makes little eye contact. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?
- A. Adjustment disorder
- B. Major depressive disorder
- C. Normal behavior
- D. Disruptive mood dysregulation disorder
- E. Depression with peripartum-onset (Correct Answer)
Postpartum depression Explanation: ***Depression with peripartum-onset***
- The patient exhibits classic symptoms of **major depressive disorder**, including **anhedonia** (loss of enjoyment in cooking), **fatigue**, **insomnia**, and **changes in appetite/weight**, all appearing within 3 weeks post-childbirth and persisting for 9 months.
- According to **DSM-5-TR**, the **peripartum onset specifier** is applied when a major depressive episode begins during pregnancy or **within 4 weeks after delivery**.
- This patient's symptoms began at 3 weeks postpartum, meeting criteria for the peripartum onset specifier, which is clinically important for risk assessment (including infanticide risk) and treatment planning.
- The severity and duration of symptoms (persistent anhedonia, significant fatigue, insomnia despite adequate opportunity for sleep, appetite changes, functional impairment lasting months) clearly meet criteria for a **major depressive episode**.
*Adjustment disorder*
- This diagnosis involves emotional or behavioral symptoms in response to an identifiable stressor that do **not meet criteria for a major depressive episode**.
- The severity, number, and duration of symptoms (anhedonia, significant fatigue, insomnia, appetite changes, functional impairment lasting 9 months) exceed what is seen in adjustment disorder and meet full criteria for **major depressive disorder**.
*Major depressive disorder*
- While this patient's symptoms fully meet criteria for **Major Depressive Disorder (MDD)**, the onset within 4 weeks postpartum requires the addition of the **"with peripartum onset" specifier** per DSM-5-TR.
- Using the peripartum onset specifier is essential for clinical management, as it alerts clinicians to specific risks (including thoughts of harming the infant) and may influence treatment selection (e.g., considerations for breastfeeding-compatible medications).
*Normal behavior*
- The patient's symptoms—including **persistent sadness lasting 9 months**, **anhedonia**, **insomnia despite adequate sleep opportunity**, **significant fatigue**, **appetite loss**, and **inability to return to work**—represent severe functional impairment.
- These symptoms far exceed normal postpartum adjustment or transient "baby blues" (which typically resolve within 2 weeks postpartum) and indicate a serious mood disorder requiring treatment.
*Disruptive mood dysregulation disorder*
- This disorder is diagnosed **only in children and adolescents aged 6-18 years** and is characterized by persistent irritability and frequent, severe temper outbursts disproportionate to the situation.
- It is **not applicable to adults** and does not describe this patient's presentation of persistent depressed mood and neurovegetative symptoms.
Postpartum depression US Medical PG Question 5: Ten days after the vaginal delivery of a healthy infant girl, a 27-year-old woman is brought to the physician by her husband because of frequent mood changes. She has been tearful and anxious since she went home from the hospital 2 days after delivery. She says that she feels overwhelmed with her new responsibilities and has difficulties taking care of her newborn because she feels constantly tired. She only sleeps for 2 to 3 hours nightly because the baby “is keeping her awake.” Sometimes, the patient checks on her daughter because she thinks she heard her cry but finds her sleeping quietly. Her husband says that she is afraid that something could happen to the baby. She often gets angry at him and has yelled at him when he picks up the baby without using a hand sanitizer beforehand. She breastfeeds the baby without any problems. The patient's mother has bipolar disorder with psychotic features. The patient's vital signs are within normal limits. Physical examination shows an involuting uterus consistent in size with her postpartum date. Mental status examination shows a labile affect with no evidence of homicidal or suicidal ideation. Laboratory studies show a hemoglobin concentration of 13 g/dL and a thyroid-stimulating hormone level of 3.1 μU/mL. Which of the following is the most appropriate next step in management?
- A. Risperidone therapy
- B. Bupropion therapy
- C. Cognitive behavioral therapy
- D. Reassurance (Correct Answer)
- E. Sertraline therapy
Postpartum depression Explanation: ***Reassurance***
- The patient exhibits symptoms of **"baby blues"**, including tearfulness, anxiety, mood swings, and feeling overwhelmed, which are common within the first two weeks postpartum and typically resolve spontaneously.
- Given the transient nature of **baby blues** and the absence of more severe symptoms like psychosis or significant functional impairment, **reassurance** and supportive care are the most appropriate initial steps.
*Risperidone therapy*
- **Risperidone** is an **antipsychotic** medication used for conditions like psychosis or severe mood disorders, which are not present in this patient's mild, transient symptoms of baby blues.
- Initiating antipsychotic therapy for **self-limiting baby blues** is unnecessary and could lead to unwanted side effects.
*Bupropion therapy*
- **Bupropion** is an **antidepressant** primarily used for major depressive disorder and seasonal affective disorder, and is not indicated for the mild, transient symptoms of **baby blues**.
- Its mechanism of action involves dopamine and norepinephrine reuptake inhibition, differing from typical SSRIs often considered for postpartum depression.
*Cognitive behavioral therapy*
- While **CBT** is an effective treatment for **postpartum depression** and anxiety disorders, the patient's symptoms are consistent with **baby blues**, which are self-limiting and resolve with supportive care in most cases.
- CBT would be more appropriate if the symptoms were severe, persistent beyond two weeks, or indicative of a more significant mood disorder.
*Sertraline therapy*
- **Sertraline** is an **SSRI antidepressant** commonly used for **postpartum depression** and anxiety, but it is not indicated for the transient and mild symptoms of **baby blues**.
- Antidepressants are typically reserved for more severe and persistent symptoms characteristic of postpartum depression, which usually lasts longer than two weeks.
Postpartum depression US Medical PG Question 6: A 25-year-old woman is brought to the emergency department by EMS after being found naked in a busy downtown square. The patient stated that she is liberating people from material desires and was found destroying objects. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam is deferred due to patient combativeness. The patient is given diphenhydramine and haloperidol and transferred to the psychiatric ward. On day 1 on the ward, the patient is no longer aggressive or agitated and has calmed down. She states that she feels severely depressed and wants to kill herself. The patient is started on a medication and monitored closely. On day 3 of the patient's stay in the hospital she is found in her room drawing up plans and states that she has major plans to revamp the current energy problems in the country. Which of the following is the most likely medication that was started in this patient?
- A. Quetiapine
- B. Olanzapine
- C. Lamotrigine
- D. Sertraline (Correct Answer)
- E. Lithium
Postpartum depression Explanation: ***Sertraline***
- This patient exhibits classic **bipolar I disorder** with rapid mood cycling from **mania** (naked in public, grandiose delusions, destroying objects) to **severe depression** (suicidal ideation on Day 1) and back to **mania** (grandiose plans on Day 3).
- The key clinical clue is the **rapid return to mania by Day 3** after starting medication during the depressive phase. This suggests **antidepressant-induced mania/mood switch**, a well-known complication of using **SSRI antidepressants** (like sertraline) **without adequate mood stabilization** in bipolar disorder.
- **Antidepressants can precipitate manic episodes** within days in bipolar patients, which is why they should be avoided or used only with concomitant mood stabilizers. This question tests recognition of this critical psychiatric principle.
*Lithium*
- Lithium is a first-line **mood stabilizer** for bipolar disorder and would be appropriate for long-term management. However, lithium **prevents manic episodes** rather than causing them.
- Lithium takes **1-2 weeks to reach therapeutic levels**, so it would not explain the rapid mood switch to mania by Day 3. If lithium had been started, we would expect **stabilization or improvement**, not a return to mania.
*Quetiapine*
- Quetiapine is an **atypical antipsychotic** effective for both acute mania and bipolar depression. It can provide rapid mood stabilization.
- If quetiapine was started on Day 1, we would expect **mood stabilization or sedation**, not a switch back to mania. Quetiapine does **not precipitate manic episodes**.
*Olanzapine*
- Olanzapine is another **atypical antipsychotic** used for acute mania and maintenance in bipolar disorder.
- Like quetiapine, olanzapine would **stabilize mood** and reduce manic symptoms, not trigger them. It would not explain the return to mania on Day 3.
*Lamotrigine*
- Lamotrigine is a mood stabilizer particularly effective for **preventing depressive episodes** in bipolar disorder, though less effective for acute mania.
- Lamotrigine **does not precipitate manic episodes** and takes weeks to titrate to therapeutic doses due to risk of Stevens-Johnson syndrome. It would not explain the rapid mood switch observed here.
Postpartum depression US Medical PG Question 7: An 18-year-old female visits your obstetrics clinic for her first prenatal checkup. It's her first month of pregnancy and other than morning sickness, she is feeling well. Upon inquiring about her past medical history, the patient admits that she used to be very fearful of weight gain and often used laxatives to lose weight. After getting therapy for this condition, she regained her normal body weight but continues to struggle with the disease occasionally. Given this history, how could her past condition affect the pregnancy?
- A. Bradycardia in newborn
- B. Seizure for mother
- C. Postpartum depression for mother (Correct Answer)
- D. Down syndrome in newborn
- E. Anemia in newborn
Postpartum depression Explanation: ***Postpartum depression for mother***
- A history of **eating disorders** significantly increases the risk of **postpartum depression** and anxiety due to psychological vulnerabilities and potential nutritional deficiencies.
- The stress of pregnancy, childbirth, and motherhood can trigger a relapse or worsen existing psychiatric conditions, making **postpartum depression** a common complication.
*Bradycardia in newborn*
- **Bradycardia** in a newborn is typically associated with conditions like fetal distress during labor, congenital heart defects, or hypoxia, not directly with a mother's past eating disorder history.
- While an eating disorder can affect maternal health, it's not a primary direct cause of neonatal **bradycardia**.
*Seizure for mother*
- **Seizures** in pregnant women are commonly linked to severe preeclampsia/eclampsia, epilepsy, or other neurological conditions.
- A past history of eating disorders does not directly predispose a mother to **seizures** during pregnancy or postpartum unless accompanied by severe electrolyte imbalances, which are usually managed.
*Down syndrome in newborn*
- **Down syndrome** is a genetic condition caused by an extra copy of chromosome 21 (Trisomy 21) and is primarily associated with advanced maternal age.
- There is no established causal link between a maternal history of **eating disorders** and the occurrence of **Down syndrome** in the newborn.
*Anemia in newborn*
- **Anemia** in a newborn can result from various factors such as maternal **anemia**, blood loss during delivery, or hemolytic disease.
- While maternal eating disorders can cause nutritional deficiencies, including maternal **anemia**, this does not directly result in **anemia** in the newborn unless those deficiencies are severe and uncorrected, or if other, more direct causes are present.
Postpartum depression US Medical PG Question 8: A 25-year-old male medical student presents to student health with a chief complaint of picking at his skin. He states that at times he has urges to pick his skin that he struggles to suppress. Typically, he will participate in the act during finals or when he has "too many assignments to do." The patient states that he knows that his behavior is not helping his situation and is causing him harm; however, he has trouble stopping. He will often ruminate over all his responsibilities which make his symptoms even worse. The patient has a past medical history of surgical repair of his ACL two years ago. His current medications include melatonin. On physical exam you note a healthy young man with scars on his arms and face. His neurological exam is within normal limits. Which of the following is the best initial step in management?
- A. Fluoxetine (Correct Answer)
- B. Dialectical behavioral therapy
- C. Interpersonal psychotherapy
- D. Clomipramine
- E. Supportive psychotherapy
Postpartum depression Explanation: ***Fluoxetine***
- This patient's symptoms are consistent with **excoriation (skin-picking) disorder**, characterized by recurrent skin picking resulting in lesions and significant distress or impairment, often triggered by stress.
- **First-line treatment** is typically **cognitive-behavioral therapy (CBT)** with habit reversal training; however, among the options provided, **selective serotonin reuptake inhibitors (SSRIs)** like fluoxetine represent the most evidence-based pharmacological approach.
- **SSRIs** are considered when psychotherapy is unavailable or as adjunctive treatment for excoriation disorder and comorbid anxiety/OCD symptoms, though evidence is mixed.
- Fluoxetine is the best option listed for initial management in this clinical scenario.
*Dialectical behavioral therapy*
- **Dialectical behavioral therapy (DBT)** is primarily used for **borderline personality disorder** and chronic suicidality, focusing on emotion regulation and distress tolerance.
- While some of its techniques could be broadly helpful, it is not the primary or most effective treatment for excoriation disorder specifically.
- **CBT with habit reversal training** would be preferred over DBT for this condition.
*Interpersonal psychotherapy*
- **Interpersonal psychotherapy (IPT)** is an evidence-based treatment mainly for **depression** and some eating disorders, focusing on improving interpersonal relationships and social functioning.
- It does not directly target the compulsive behaviors or urge suppression central to excoriation disorder.
*Clomipramine*
- **Clomipramine**, a tricyclic antidepressant (TCA), is effective for **obsessive-compulsive disorder (OCD)**, but it has a less favorable side effect profile than SSRIs.
- Due to its side effects and lower tolerability, it is usually reserved for cases resistant to SSRIs, making it not the best initial pharmacologic step.
*Supportive psychotherapy*
- **Supportive psychotherapy** aims to alleviate symptoms, maintain self-esteem, and improve coping skills, offering a general supportive environment.
- While it can be helpful as an adjunct, it lacks the specific behavioral or pharmacological mechanisms needed for effective treatment of excoriation disorder.
Postpartum depression US Medical PG Question 9: A 28-year-old woman presents with depressed mood lasting for most days of the week for the past month. She also mentions that she has lost her appetite for the past 3 weeks. She adds that her job performance has significantly deteriorated because of these symptoms, and she feels like she will have to quit her job soon. Upon asking about her hobbies, she says that she used to enjoy dancing and music but does not have any desire to do them anymore. The patient’s husband says that she has had many sleepless nights last month. The patient denies any history of smoking, alcohol intake, or use of illicit substances. No significant past medical history. Physical examination is unremarkable. Routine laboratory tests are all within normal limits. Which of the following clinical features must be present, in addition to this patient’s current symptoms, to confirm the diagnosis of a major depressive episode?
- A. Intense fear of losing control
- B. Lack of concentration (Correct Answer)
- C. Weight loss
- D. Anterograde amnesia
- E. Nightmares
Postpartum depression Explanation: ***Lack of concentration***
- The diagnostic criteria for a **major depressive episode** (DSM-5) require at least **5 out of 9 cardinal symptoms** present for at least 2 weeks, with at least one being either **depressed mood** or **anhedonia**.
- This patient currently has **4 symptoms**: (1) depressed mood, (2) anhedonia (loss of interest in dancing/music), (3) appetite disturbance (loss of appetite), and (4) sleep disturbance (insomnia).
- To meet diagnostic criteria, she needs **one more symptom** from the remaining options: fatigue, feelings of worthlessness/guilt, **diminished ability to concentrate or indecisiveness**, psychomotor changes, or suicidal ideation.
- **Lack of concentration** is one of the DSM-5 diagnostic criteria and would bring her total to 5 symptoms, confirming the diagnosis.
*Intense fear of losing control*
- This symptom is characteristic of **panic disorder** or anxiety disorders, where individuals experience sudden, intense episodes of fear with accompanying physical and cognitive symptoms.
- While anxiety can co-occur with depression, intense fear of losing control is **not a DSM-5 diagnostic criterion** for major depressive episode.
*Weight loss*
- The patient already has **loss of appetite**, which satisfies the weight/appetite criterion for major depressive episode.
- **Weight loss and appetite changes are part of the same diagnostic criterion**, not separate ones. Therefore, weight loss would not add an additional criterion to reach the required 5 symptoms.
- While clinically significant weight loss can occur in depression, it would not provide the "additional" criterion needed in this case.
*Anterograde amnesia*
- **Anterograde amnesia** (inability to form new memories) is associated with neurological conditions such as **hippocampal damage**, **Korsakoff syndrome**, or **traumatic brain injury**.
- It is **not a DSM-5 diagnostic criterion** for major depressive episode, though some cognitive impairment (concentration difficulties) may occur.
*Nightmares*
- The patient already has **insomnia** (sleep disturbance), which is one of the DSM-5 diagnostic criteria.
- While nightmares may occur in depression, they are not a separate diagnostic criterion and would not add to the symptom count since sleep disturbance is already present.
Postpartum depression US Medical PG Question 10: A 52-year-old man presents with a 1-month history of a depressed mood. He says that he has been “feeling low” on most days of the week. He also says he has been having difficulty sleeping, feelings of being worthless, difficulty performing at work, and decreased interest in reading books (his hobby). He has no significant past medical history. The patient denies any history of smoking, alcohol use, or recreational drug use. A review of systems is significant for a 7% unintentional weight gain over the past month. The patient is afebrile and his vital signs are within normal limits. A physical examination is unremarkable. The patient is prescribed sertraline 50 mg daily. On follow-up 4 weeks later, the patient says he is slightly improved but is still not feeling 100%. Which of the following is the best next step in the management of this patient?
- A. Switch to a different SSRI
- B. Continue sertraline (Correct Answer)
- C. Add buspirone
- D. Switch to an MAOI
- E. Add aripiprazole
Postpartum depression Explanation: ***Continue sertraline***
- Many antidepressants, including SSRIs like sertraline, require **4-6 weeks at a therapeutic dose** to achieve their full effect. Since the patient reports slight improvement after 4 weeks, continuing the current medication allows more time for optimal response.
- The goal is for the patient to feel "100%", which often takes longer than one month. **Gradual improvement** after initial therapy suggests the medication is working, but needs more time.
*Switch to a different SSRI*
- Switching to another SSRI is typically considered if there is **no improvement or significant intolerance** after an adequate trial (at least 4-6 weeks) at a therapeutic dose of the initial SSRI.
- This patient has shown *slight improvement*, indicating that sertraline may still be effective with more time.
*Add buspirone*
- Buspirone is an **anxiolytic medication** sometimes used as an augmentation strategy for depression, particularly if anxiety is a prominent symptom.
- However, it's generally added *after* an initial antidepressant has failed to achieve a full response, and typically *after* optimizing the dose and duration of the primary antidepressant.
*Switch to an MAOI*
- **Monoamine oxidase inhibitors (MAOIs)** are older antidepressants with a more challenging side effect profile and significant drug-drug and drug-food interactions.
- They are typically reserved for patients who have **failed multiple trials of other antidepressants** due to their safety concerns.
*Add aripiprazole*
- Aripiprazole, an **atypical antipsychotic**, is sometimes used as an augmentation strategy for **treatment-resistant depression**.
- This approach is usually considered when trials of several different antidepressant classes have failed or when the depression has not responded adequately to optimized antidepressant therapy.
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