MB, a 26-year old female presents to her general practitioner with complaints of consistent depressive episodes for the past 3 months. MB realizes her depression is impacting her daily life and wants to make a change. MB’s only concern is the rumors she’s heard regarding antidepressants causing extra weight gain. MB’s laboratory findings and vitals are below:

Past medical history:

Anorexia Nervosa

Labs/Vitals:

Ht: 5’4 ft

Wt: 120 lbs

BP: 126/78 mmHg

HR: 68 BPM

Temp: 98.4 F

Glucose: 75 mg/dL (70-130 mg/dL)

Scr: 0.9 mg/dL (0.5-1.2 mg/dL)

Na: 140 mEq/L (135-145 mEq/L)

Cl: 102 mEq/L (95-105 mEq/L)

K: 3.9 mEq/L (3.5-5 mEq/L)

Ca: 8.7 mg/dL (8.5-10.5 mg/dL)

Mg: 1.9 mg/dL (1.7-2.2 mg/dL)

Given MB’s concerns, which antidepressant is the most appropriate option for her practitioner to prescribe?

A. Buspirone 7.5 mg PO BID

B. Fluoxetine 10 mg PO once daily

C. Bupropion 150 mg PO BID

D. Paroxetine 40 mg PO once daily 

Answer with rationale:

Psychological conditions such as major depressive disorder and generalized anxiety disorder have a strong correlation of occurring as comorbidities with eating disorders. Treating a condition such as depression, while simultaneously not disrupting the recovery process of an eating disorder is a delicate balance. Select serotonin reuptake inhibitors (SSRIs) increase the amount of serotonin available to the brain and result in an overall improvement of the patient’s mood. SSRIs can be associated with weight gain, weight loss, or classified as weight neutral. While the percent of weight gain from select antidepressants can vary, the contraindications and weight influence of each antidepressant should be taken into consideration prior to prescribing.

Answer A is incorrect. Buspirone is classified as a “weight neutral” medication but should not be used in the treatment of major depression disorder. Buspirone currently has FDA approval only for the treatment of anxiety disorders.

Answer B is correct. Fluoxetine is indicated for the treatment and maintenance of depression. Fluoxetine is generally classified as “weight neutral” and would be a reasonable option for our patient. This is also an appropriate starting dose. 

Answer C is incorrect. Bupropion is FDA approved for treating depression, seasonal affective disorder, and smoking cessation. Bupropion can intensity weight loss and should be avoided in patients with an active or prior history of an eating disorder. The specific patient in the case above has a past medical history of anorexia nervosa and should not be prescribed bupropion.

Answer D is incorrect. While paroxetine is indicated in the treatment of major depressive disorder, it is not the ideal initial treatment choice for this patient due to the dose of 40mg daily. Patients should generally start with 10mg or 20mg daily. Also, paroxetine among the SSRIs is associated with the most weight gain making it least appropriate for our patient.  

Brand/generics Covered:

Buspirone (BuSpar), Prozac (Fluoxetine), Bupropion (Wellbutrin), Sertraline (Zoloft)