From the Guidelines
The best approach for this patient would be to add bupropion (Wellbutrin) 150-300 mg daily to his current sertraline regimen, as bupropion has been associated with a lower rate of sexual adverse events than fluoxetine and sertraline, and works well with SSRIs to help with energy and motivation 1.
Considerations for Treatment-Resistant MDD
When treating acute-phase major depressive disorder (MDD), second-generation antidepressants do not significantly differ in efficacy, effectiveness, or quality of life, as shown in studies such as STAR*D (Sequenced Treatment Alternatives to Relieve Depression) 1.
- Mirtazapine has a significantly faster onset of action than other antidepressants, but after 4 weeks, most response rates are similar 1.
- Almost 38% of patients do not achieve a treatment response during 6 to 12 weeks of treatment with second-generation antidepressants, and 54% do not achieve remission 1.
- Second-generation antidepressants do not differ in the rate of achieving remission, and the choice of medication should be based on adverse effect profiles, cost, and patient preferences 1.
Augmentation Strategies
If the patient's symptoms do not improve with the addition of bupropion, alternative augmentation strategies could include:
- Switching to another antidepressant like venlafaxine (Effexor) 75-225 mg daily or escitalopram (Lexapro) 10-20 mg daily 1.
- Continuing psychotherapy alongside medication management, as it is essential for improving treatment outcomes and reducing the risk of relapse 1.
Monitoring and Follow-up
Given the patient's family history of depression and cardiac issues, close monitoring is essential, particularly when initiating or changing medications. Regular follow-up appointments should be scheduled to assess the patient's response to treatment and adjust the medication regimen as needed.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Elderly Man with Treatment-Resistant MDD on Sertraline
- The patient is currently on sertraline, but it is not effective in treating his major depressive disorder (MDD) 2.
- One possible approach is to add a low-dose aripiprazole to the patient's current sertraline regimen, as studies have shown that adjunctive low-dose aripiprazole can augment the efficacy of regular-dose sertraline in treating major depressive disorder 3.
- Another option is to optimize the dose of sertraline, as the optimal dose for most patients is between 20 mg and 40 mg fluoxetine equivalents, and the patient is currently taking 100 mg per day 4, 5.
- If the patient does not respond to these options, other antidepressants such as agomelatine, amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine may be considered, as they have been shown to be more effective than other antidepressants in head-to-head studies 6.
Considerations for Treatment
- When selecting a treatment, it is essential to consider the patient's age, medical history, and potential interactions with other medications 2, 5.
- The patient's dosage of sertraline may need to be adjusted, and the addition of other medications such as aripiprazole may be necessary to achieve optimal treatment outcomes 3, 4.
- Regular monitoring of the patient's symptoms and side effects is crucial to ensure the effectiveness and safety of the treatment regimen 2, 6.