SSRI Partial Response with Persistent Symptoms

Clinical History

‍36-year-old male with MDD on sertraline 150mg for 12 weeks. Sleep and appetite improved, but still has low mood, poor concentration, and anhedonia. PHQ-9 went from 18 to 12. No SI, no substance use, no history of mania or psychosis. Prefers not to switch medications.

Clinical Question

‍He’s better but not well. What can I add in primary care, and how far can I take this before it needs a higher level of care?

Specialist Guidance

‍Partial response after an adequate trial is common and doesn’t mean you need to refer to psychiatry. Since he’s had benefit from sertraline and wants to stay on it, augmentation makes more sense than switching. Start with bupropion XL 150mg.

The residual symptoms you’re describing (concentration, anhedonia) are exactly what bupropion tends to help with. Low sexual side effect profile, straightforward to monitor. Aripiprazole 2–5mg is another option (FDA-approved for MDD augmentation) but needs more monitoring for akathisia and metabolic effects, so try bupropion first. Give it 6–8 weeks. If the response is partial, there’s room to titrate: sertraline can go to 200mg and bupropion to 300mg before you’ve exhausted primary care options.

Switching to a different SSRI is also reasonable if the patient becomes open to it. Psychiatry referral would be appropriate if symptoms persist despite optimized doses of both agents, or if diagnostic complexity emerges. Make sure he’s connected to therapy. Medication plus psychotherapy outperforms either alone for moderate-to-severe depression, and that combination is often the missing piece.

Outcome

‍Added bupropion XL 150mg. PHQ-9 improved to 7 at 8 weeks. Concentration and energy improved. Psychotherapy referral facilitated. Managed entirely in primary care. No psychiatry referral required.

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