What are the medication recommendations for managing major depressive disorder (MDD) and generalized anxiety disorder (GAD) in a 71-year-old woman with a history of trauma and ongoing emotional abuse?

From the Guidelines

For a 71-year-old woman with MDD, GAD, trauma history, and ongoing emotional abuse, selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line treatment, prioritizing depressive symptoms, as suggested by the most recent guideline update 1. Specifically, sertraline (starting at 25mg daily, gradually increasing to 50-100mg) or escitalopram (starting at 5mg daily, increasing to 10mg) would be appropriate due to their favorable side effect profiles in older adults and efficacy for both depression and anxiety. Treatment should continue for at least 6-12 months after symptom resolution, with careful monitoring for side effects like nausea, insomnia, or hyponatremia. Start with lower doses than typically used in younger adults and increase slowly ("start low, go slow"). Adjunctive psychotherapy, particularly trauma-focused cognitive behavioral therapy, is strongly recommended alongside medication, as it can address both depression and anxiety symptoms, as well as the trauma history and ongoing emotional abuse, as supported by recent studies 1. The patient should also be connected with resources for addressing the ongoing emotional abuse, as medication alone cannot resolve environmental factors contributing to her symptoms. SSRIs are preferred over tricyclic antidepressants or benzodiazepines in this age group due to reduced risk of anticholinergic effects, cardiac issues, and falls, as noted in previous research 1. Given the patient's current medications, including fluoxetine 20 mg daily and mirtazapine 15 mg at bedtime, a careful assessment of the need for adjustment or augmentation should be made, considering the potential benefits and harms of each treatment option, as well as the patient's preferences and values. Ultimately, the goal of treatment should be to improve the patient's quality of life, reduce symptoms of depression and anxiety, and address the underlying trauma and emotional abuse, with a comprehensive approach that incorporates both pharmacologic and non-pharmacologic interventions.

From the FDA Drug Label

Maintenance/Continuation/Extended Treatment It is generally agreed that acute episodes of major depressive disorder require several months or longer of sustained pharmacologic therapy. Daily Dosing Systematic evaluation of Prozac in adult patients has shown that its efficacy in major depressive disorder is maintained for periods of up to 38 weeks following 12 weeks of open–label acute treatment (50 weeks total) at a dose of 20 mg/day

The patient is currently taking fluoxetine 20 mg daily, which is within the recommended dose range for managing major depressive disorder (MDD).

• The medication regimen for this patient should be continued, considering the patient's stable appetite and fair concentration.
• However, the patient's generalized anxiety disorder (GAD) and ongoing emotional abuse should be addressed through non-pharmacological interventions, such as counseling and support groups.
• The patient's mirtazapine 15 mg at bedtime may also be contributing to the management of depressive symptoms and anxiety.
• No changes to the medication regimen are recommended at this time, but the patient should be monitored closely for any changes in symptoms or behavior. 2
• It is essential to screen patients for bipolar disorder before initiating treatment with an antidepressant, considering the patient's depressive symptoms. 2

From the Research

Medication Recommendations for Managing MDD and GAD

The patient's history of trauma and ongoing emotional abuse, along with her diagnosis of major depressive disorder (MDD) and generalized anxiety disorder (GAD), require careful consideration of medication options.

• Current medications include fluoxetine 20 mg daily, mirtazapine 15 mg at bedtime, and memantine 5Ymg twice daily.
• Studies have shown that mirtazapine can be effective in treating MDD with comorbid GAD, with significant reductions in Hamilton Rating Scale for Depression scores, Hamilton Rating Scale for Anxiety scores, and Beck Depression Inventory scores 3.
• A comparison of mirtazapine and fluoxetine in the treatment of MDD found that both drugs were equally effective and well-tolerated after 6 weeks of treatment 4.
• Another study found that mirtazapine was as well-tolerated as fluoxetine and significantly more effective after 3 and 4 weeks of therapy 5.
• The network structure of MDD, GAD, and somatic symptomatology has been explored, showing numerous associations between MDD/GAD and somatic symptoms, with individual symptoms varying substantially in their connections to the somatic domain 6.

Considerations for Medication Adjustments

Given the patient's complex history and current medication regimen, any adjustments to her medications should be made with caution and careful monitoring.

• The patient's current dose of mirtazapine is 15 mg at bedtime, which is within the recommended dose range for MDD and GAD.
• The patient's current dose of fluoxetine is 20 mg daily, which is a common dose for MDD and GAD.
• Consideration should be given to the patient's history of trauma and ongoing emotional abuse, as well as her symptoms of anxiety and depression, when adjusting her medication regimen.
• Psychotherapy, such as cognitive behavioral therapy (CBT), interpersonal therapy, or supportive therapy, may also be beneficial in managing the patient's MDD and GAD, as it has been shown to be effective in reducing symptoms of depression and anxiety 7.