What adjustments can be made to the medication regimen of a 77-year-old female patient taking duloxetine (60 mg) and trazodone (50 mg) at bedtime who exhibits lack of motivation and increased depression?

From the Guidelines

For a 77-year-old female patient with worsening depression and lack of motivation while on duloxetine 60 mg and trazodone 50 mg at bedtime, I recommend optimizing the duloxetine dose by increasing it to 90-120 mg daily if tolerated, as higher doses may provide better antidepressant efficacy, as suggested by the American College of Physicians guidelines 1.

Key Considerations

• The patient's lack of motivation and increased depression suggest that the current medication regimen may not be adequate, and adjustments are necessary to improve outcomes.
• Increasing the duloxetine dose to 90-120 mg daily may provide better antidepressant efficacy, but it is essential to monitor for side effects, particularly given the patient's advanced age.
• Augmentation strategies, such as adding bupropion XL 150 mg in the morning or low-dose aripiprazole 2-5 mg daily, may be considered if the patient does not respond to the optimized duloxetine dose.

Monitoring and Evaluation

• Regular monitoring of the patient's response to treatment, including assessment of depressive symptoms, motivation, and side effects, is crucial to determine the effectiveness of the adjusted medication regimen.
• The patient should be evaluated for medication side effects, medical conditions affecting mood, and psychosocial factors that may be contributing to the worsening depression.
• Blood pressure, heart rate, and sodium levels should be checked regularly, especially if increasing the duloxetine dose, to minimize the risk of adverse effects.

Recommendations

• The American College of Physicians recommends modifying treatment if the patient does not have an adequate response to pharmacotherapy within 6 to 8 weeks of the initiation of therapy for major depressive disorder 1.
• Clinicians should assess patient status, therapeutic response, and adverse effects of antidepressant therapy on a regular basis, beginning within 1 to 2 weeks of initiation of therapy 1.
• The patient's treatment plan should be adjusted based on the comprehensive evaluation and monitoring results to ensure the best possible outcome.

From the FDA Drug Label

2.2 Dosage for Treatment of Major Depressive Disorder in Adults The recommended starting dosage in adults with MDD is 40 mg/day (given as 20 mg twice daily) to 60 mg/day (given either once daily or as 30 mg twice daily) For some patients, it may be desirable to start at 30 mg once daily for 1 week, to allow patients to adjust to duloxetine delayed-release capsules before increasing to 60 mg once daily. While a 120 mg/day dose was shown to be effective, there is no evidence that doses greater than 60 mg/day confer any additional benefits Periodically reassess to determine the need for maintenance treatment and the appropriate dosage for such treatment.

The patient is already taking the maximum recommended dose of 60 mg/day for MDD. No adjustment to the duloxetine dose is recommended. Consideration should be given to adjusting the concomitant medication, trazodone, or adding another medication to the treatment regimen, but this information is not provided in the duloxetine drug label 2.

From the Research

Adjustment to Medication Regimen

To address the lack of motivation and increased depression in a 77-year-old female patient taking duloxetine (60 mg) and trazodone (50 mg) at bedtime, several adjustments can be considered:

• Increasing the dose of duloxetine, as studies have shown that higher doses (up to 120 mg/day) can be safe and tolerable 3
• Switching to a different antidepressant, such as bupropion, which has been shown to be effective in patients with SSRI-resistant major depression 4
• Adding a second antidepressant or augmenting with a nonantidepressant medication, as these strategies have been found to have approximately equal likelihood of success 5

Addressing Lack of Motivation

Lack of motivation is a core feature of major depression, and increasing motivation has been shown to improve memory and cognitive function in patients with major depression 6

• Motivational interventions, such as cognitive therapy or behavioral activation, may be beneficial in improving motivation and overall depressive symptoms 5, 6

Considerations for Treatment

When adjusting the medication regimen, it is essential to consider the patient's individual symptoms, medical history, and potential interactions with other medications

• A collaborative care approach, including systematic follow-up and outcome assessment, can improve treatment effectiveness 5
• Close monitoring of the patient's response to treatment and adjustments to the medication regimen as needed can help optimize treatment outcomes 5, 3