What medication should be added or changed for a 46-year-old male with Major Depressive Disorder (MDD) taking 150mg sertraline (Zoloft), who exhibits symptoms of Attention Deficit Hyperactivity Disorder (ADHD) and complains of demotivation, low energy, and insomnia?

Medication Management for MDD with ADHD Symptoms and Insomnia

For a 46-year-old male with MDD taking sertraline 150mg who exhibits symptoms of ADHD, demotivation, low energy, and insomnia, bupropion should be added to the current regimen as the most appropriate medication intervention. 1, 2

Assessment of Current Situation

The patient is currently experiencing:

• Inadequate response to sertraline 150mg for MDD
• Symptoms suggesting ADHD
• Persistent low energy and motivation issues
• Sleep disturbances

Medication Recommendation Algorithm

Step 1: Evaluate Current Medication Efficacy

• Sertraline at 150mg is within therapeutic range but not providing adequate symptom control
• The patient's complaints of feeling "not themselves" suggests partial response to the SSRI

Step 2: Address ADHD Symptoms

Bupropion is the optimal choice for several reasons:

• It has documented efficacy for ADHD symptoms 1, 3
• It has activating properties that can address low energy and motivation 1
• It can be safely co-administered with sertraline 4
• It provides antidepressant augmentation while targeting ADHD symptoms 3

Step 3: Dosing Recommendations

• Start bupropion XL at 150mg once daily in the morning 2
• After 4 days, increase to target dose of 300mg once daily if tolerated 2
• Maintain current sertraline dose of 150mg

Evidence-Based Rationale

Bupropion offers several advantages in this clinical scenario:

• It is described as "activating" and can "rapidly improve energy level" 1
• It specifically addresses the patient's complaints of demotivation and low energy
• It has documented efficacy in ADHD 1, 3
• The combination of an SSRI with bupropion has been shown to be effective and well-tolerated for comorbid depression and ADHD 4

Sleep Management Considerations

For the patient's insomnia:

• Bupropion should be administered in the morning to minimize sleep disruption 1
• If insomnia persists after bupropion addition, consider:
  1. Implementing cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment 1
  2. Stimulus control and sleep restriction techniques 1
  3. If needed, low-dose trazodone could be considered as an adjunct specifically for sleep 1

Important Monitoring Parameters

• Monitor for improvement in energy, motivation, and attention within 1-2 weeks
• Assess for potential side effects:
  • Increased anxiety or agitation
  • Worsening insomnia
  • Blood pressure changes
  • Seizure risk (rare but important)
• Evaluate response after 4-6 weeks of combined therapy

Common Pitfalls to Avoid

1. Increasing sertraline dose: This would likely worsen insomnia and may not address ADHD symptoms
2. Adding a sedating antidepressant alone: While this might help with sleep, it could worsen daytime energy and ADHD symptoms
3. Starting stimulant medication first-line: While effective for ADHD, this approach may exacerbate insomnia and anxiety in a patient with partial response to antidepressant therapy
4. Ignoring the ADHD component: Treating only the depression without addressing attention symptoms would likely result in continued functional impairment

Bupropion's unique profile makes it particularly well-suited for this patient's constellation of symptoms, addressing both the mood and attention components while potentially improving energy and motivation.