What are the recommendations for a 37-year-old patient with a history of Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD), currently on Wellbutrin (bupropion) 150mg twice daily (bid) and Lexapro (escitalopram) 10mg once daily (qd), with persistent low motivation and depressed mood?

From the Guidelines

For a 37-year-old patient with MDD and GAD experiencing persistent low motivation and depressed mood despite current treatment with Wellbutrin 150mg bid and Lexapro 10mg qd, I recommend assessing the patient's response to the current medication regimen and considering optimization or augmentation strategies, as the current treatment may not be adequate according to the definition of treatment-resistant depression (TRD) 1.

To determine the best course of action, it's essential to evaluate the patient's current medication regimen and response. The patient is currently taking Wellbutrin (bupropion) 150mg bid and Lexapro (escitalopram) 10mg qd, which may not be sufficient to address the patient's symptoms. According to the study by 1, a patient should have at least two previous treatments with established medications for MDD, with different mechanisms of action, to be considered as having TRD.

Some key points to consider:

• The patient's current medication regimen should be optimized before considering alternatives, including ensuring the patient has been on the current regimen for at least 4-6 weeks 1.
• Increasing Lexapro to 20mg daily may be beneficial, as this is the therapeutic dose for many patients with depression and anxiety.
• Augmentation strategies, such as adding low-dose aripiprazole (2-5mg daily) or switching the Wellbutrin to another antidepressant with a different mechanism of action, such as venlafaxine or duloxetine, may be considered if the patient's symptoms persist.
• Psychotherapy, particularly cognitive behavioral therapy (CBT), should be recommended alongside medication management, as it can be an effective treatment strategy for TRD 1.

The patient's treatment plan should be tailored to their individual needs, and a comprehensive approach that addresses both medication management and lifestyle factors, such as sleep, exercise, and nutrition, is crucial to providing optimal symptom relief.

Some potential next steps:

• Evaluate the patient's response to the current medication regimen and consider optimization or augmentation strategies.
• Consider adding psychotherapy, such as CBT, to the patient's treatment plan.
• Ensure the patient is educated on the importance of lifestyle factors, such as sleep, exercise, and nutrition, in managing their symptoms.

From the FDA Drug Label

The recommended dose of Escitalopram tablets is 10 mg once daily. A fixed-dose trial of Escitalopram demonstrated the effectiveness of both 10 mg and 20 mg of Escitalopram, but failed to demonstrate a greater benefit of 20 mg over 10 mg [see Clinical Studies (14. 1)]. If the dose is increased to 20 mg, this should occur after a minimum of one week. Consider changing the therapeutic regimen, including possibly discontinuing escitalopram tablets, in patients whose depression is persistently worse, or who are experiencing emergent suicidal thoughts or behaviors.

The patient is currently on Lexapro (escitalopram) 10mg qd and Wellbutrin (bupropion) 150mg bid. Given the patient's persistent low motivation and depressed mood, the following options could be considered:

• Increasing the dose of Lexapro to 20mg qd after a minimum of one week, as the fixed-dose trial demonstrated the effectiveness of both 10mg and 20mg of Escitalopram.
• Considering alternative therapeutic regimens, including possibly discontinuing Lexapro or Wellbutrin, in patients whose depression is persistently worse.
• Monitoring the patient for any indication of clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy, and at times of dosage changes 2.

From the Research

Medication Recommendations

The patient is currently on Wellbutrin (bupropion) 150mg twice daily and Lexapro (escitalopram) 10mg once daily, with Vistaril 50mg twice daily as needed for anxiety. Given the patient's persistent low motivation and depressed mood, the following recommendations can be considered:

• The combination of bupropion and an SSRI (such as escitalopram) is generally well tolerated and can be effective for treating major depressive disorder (MDD) 3.
• Escitalopram has been shown to be effective in improving quality of life enjoyment and satisfaction in patients with MDD and generalized anxiety disorder (GAD) 4.
• Bupropion can be used to enhance antidepressant response and ameliorate antidepressant-associated sexual dysfunction 3.
• The patient's current dosage of bupropion (150mg twice daily) is within the recommended range, but the dosage of escitalopram (10mg once daily) may be considered low for some patients 5.

Potential Adjustments

Consider the following potential adjustments to the patient's medication regimen:

• Increasing the dosage of escitalopram to 20mg once daily, as this has been shown to be effective in treating MDD and GAD 5.
• Continuing the current dosage of bupropion (150mg twice daily), as this can help to enhance antidepressant response and ameliorate sexual side effects 3.
• Monitoring the patient's response to the current medication regimen and adjusting as needed to optimize treatment outcomes.

Considerations

When making adjustments to the patient's medication regimen, consider the following:

• The patient's medical history and current symptoms, including low motivation and depressed mood.
• The potential for drug interactions between bupropion and escitalopram, as well as other medications the patient may be taking 6, 3.
• The importance of regular follow-up appointments to monitor the patient's response to treatment and adjust the medication regimen as needed.