From the Guidelines
For a patient with a partial response to vortioxetine (Brintellix), the next step would typically be to optimize the current dose before considering alternative strategies, as recommended by the American College of Physicians 1. First, ensure the patient has reached an adequate therapeutic dose, which can range from 10-20 mg daily, with some patients requiring the maximum approved dose of 20 mg daily to achieve full benefit. If the patient has been on an optimized dose for at least 4-6 weeks with only partial improvement, consider augmentation strategies such as:
- Adding bupropion (150-300 mg daily)
- Aripiprazole (2-15 mg daily)
- Lithium (aiming for blood levels of 0.6-0.8 mEq/L), as these have been found to provide similar symptomatic relief in patients who did not achieve remission with an initial antidepressant 1. Alternatively, switching to another antidepressant with a different mechanism of action, such as an SNRI like venlafaxine (75-225 mg daily) or duloxetine (60-120 mg daily), may be beneficial. Throughout this process, it's essential to continue psychotherapy if already established and address any lifestyle factors that might be impeding recovery, as nonpharmacologic treatments have been found to have similar efficacy to second-generation antidepressants as first-step treatments for adult outpatients with moderate to severe major depressive disorder (MDD) 1. These approaches are based on the understanding that depression often requires multimodal treatment, and vortioxetine's unique mechanism as a serotonin modulator may not fully address all neurochemical imbalances in some patients. The choice of treatment should be based on patient preferences, experiences with previous treatments, and the advantages and disadvantages of each treatment option, with consideration of the potential risks and benefits, including adverse event profiles 1.
From the Research
Next Steps for Partial Response to Vortioxetine
If a patient has a partial response to vortioxetine, several options can be considered:
- Increasing the dose of vortioxetine, as studies have shown that higher doses (20 mg/day) can lead to greater improvement in depressive symptoms compared to lower doses (10 mg/day) 2
- Augmenting the treatment regimen with a nonantidepressant agent, such as atypical antipsychotic agents, lithium, or omega-3 fatty acids, which have been shown to be effective in treating antidepressant nonresponders 3
- Combining vortioxetine with a second antidepressant, such as bupropion, mirtazapine, or venlafaxine, which can be an effective strategy for treating partial response or nonresponse to antidepressants 3
- Switching to a different antidepressant, such as duloxetine, escitalopram, levomilnacipran, sertraline, venlafaxine, or vilazodone, which have been compared to vortioxetine in terms of efficacy and tolerability 4
Considerations for Treatment Strategies
When choosing the best treatment strategy for a patient with a partial response to vortioxetine, several factors should be taken into account:
- Efficacy and tolerability of the treatment
- Patient preference and treatment history
- Risk of potential loss of partial therapeutic benefit from the first-line antidepressant
- Risk of withdrawal symptoms
- Risk of drug interactions and poor adherence 3
Vortioxetine's Mechanism of Action
Vortioxetine's unique psychopharmacological properties, including its multimodal mechanism of action, may contribute to an improved clinical outcome in patients with major depressive disorder 5, 6
- Vortioxetine has been shown to be effective in treating depressive symptoms and cognitive deficits in patients with major depressive disorder
- Its mechanism of action combines 5-HT reuptake inhibition with modulations of other key pre- and post-synaptic 5-HT receptors, which can explain its dose-dependent effect and improved tolerability profile 6