From the Guidelines
The patient's current medication regimen of Wellbutrin 300mg and Celexa 10mg should be adjusted as soon as possible, given that their depression symptoms are worsening, and this adjustment should be made within 6 to 8 weeks of initiation of therapy, as recommended by the American College of Physicians 1. The current dose of Celexa at 10mg may be insufficient, and increasing it to 20mg could be considered, as many patients require higher doses for a full therapeutic effect. Alternatively, switching to another SSRI like sertraline or escitalopram, or to a different class of antidepressant altogether, might be necessary.
- The Wellbutrin 300mg dose is already at a therapeutic level, but its formulation (XL vs SR) and potential side effects should be evaluated.
- It is crucial for the patient to report specific symptoms and their timing to the healthcare provider, including sleep changes, energy levels, and any suicidal thoughts, as worsening depression despite medication requires prompt medical attention.
- The patient should be closely monitored for increases in suicidal thoughts and behaviors, agitation, irritability, or unusual changes in behavior, as these can indicate that the depression is getting worse, especially during the first 1 to 2 months of treatment 1.
- The healthcare provider should consider whether the addition of other therapeutic modalities, such as psychotherapy, may be indicated, as the response rate to drug therapy may be as low as 50% 1.
From the FDA Drug Label
Instruct patients, their families, and/or their caregivers to be alert to the emergence of ... worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down. The patient's depression symptoms are worsening while on Wellbutrin 300mg and Celexa 10mg.
- The FDA drug label for bupropion warns of worsening of depression as a possible side effect, especially early during antidepressant treatment.
- It is recommended to closely monitor the patient and consider changes in medication if symptoms persist or worsen 2.
From the Research
Treatment Options for Depression
The patient is currently taking Wellbutrin 300mg and Celexa 10mg, but their depression symptoms have worsened. Considering alternative treatment options is essential.
- Combining antidepressants may be an effective approach, as shown in a study published in 2022 3, which found that combination treatment was statistically significantly associated with superior treatment outcomes relative to monotherapy.
- Another study published in 2021 4 compared the efficacy and tolerability of combination treatments for major depression, including antidepressants plus second-generation antipsychotics, esketamine, and lithium, and found that lithium was somewhat more effective and better tolerated.
- A study published in 2012 5 compared citalopram with other antidepressants and found that citalopram was more efficacious than paroxetine and reboxetine and more acceptable than tricyclics, reboxetine, and venlafaxine.
- In terms of specific medication combinations, a study published in 2004 6 found that combining citalopram and bupropion-SR was more effective than switching to a monotherapy in patients with treatment-resistant depression.
Considerations for Treatment-Resistant Depression
For patients with treatment-resistant depression, combining medications or switching to a different medication may be necessary.
- A study published in 2013 7 found that both SSRIs and tricyclic antidepressants are efficacious in the treatment of chronic depression, but SSRIs showed better acceptability in terms of dropout rates.
- The study published in 2021 4 also found that second-generation antipsychotics, esketamine, and lithium may be useful adjuncts to antidepressants for acute major depressive episodes, but the risk/benefit ratio should be carefully considered.
Next Steps
Given the patient's worsening depression symptoms, it may be necessary to reassess their treatment plan and consider alternative options, such as combining medications or switching to a different medication. Consultation with a healthcare professional is essential to determine the best course of treatment.