What are the best treatment options for a patient with significant anxiety and a history of self-harm on Wellbutrin (bupropion), currently taking escitalopram (20mg)?

Treatment Options for Significant Anxiety with History of Self-Harm

For a patient with significant anxiety and a history of self-harm on Wellbutrin (bupropion) who is currently taking escitalopram 20mg, the best treatment option is to add cognitive behavioral therapy (CBT) while maintaining the current escitalopram dose, rather than switching to or adding another medication.

Current Situation Assessment

The patient presents with:

• Significant anxiety (GAD score of 21)
• Severe depression (PHQ-9 score of 24)
• Current treatment: escitalopram 20mg
• History of self-harm while on Wellbutrin (bupropion)

Treatment Recommendations

First-line Approach

1. Continue escitalopram 20mg

   • The patient is already at the maximum recommended dose of escitalopram for anxiety disorders 1
   • Escitalopram has demonstrated efficacy for both anxiety and depression 2
   • Current dose should be maintained as it represents the optimal therapeutic dose

2. Add Cognitive Behavioral Therapy (CBT)

   • Low-quality evidence shows no difference in response or remission when switching from an SSRI to another medication versus switching to cognitive therapy 1
   • CBT has shown comparable efficacy to medication for anxiety disorders 1
   • Combination treatment (medication + CBT) may be more effective than either treatment alone 1

Medications to Avoid

1. Avoid reintroducing bupropion
   • Patient has history of self-harm on bupropion
   • Bupropion is associated with significantly higher risk of serious outcomes in overdose compared to SSRIs 3
   • In cases of overdose, bupropion is associated with higher rates of seizures (27.0% vs 8.5%), hallucinations (28.6% vs 4.3%), and death (0.23% vs 0%) compared to SSRIs 3

Alternative Options (if first-line approach fails)

1. Consider augmentation with buspirone

   • Low-quality evidence showed no difference in response or remission for augmentation of SSRI treatment with buspirone compared to other options 1
   • Moderate-quality evidence showed that discontinuation due to adverse events was higher with buspirone than with some alternatives 1

2. Consider switching to sertraline

   • If escitalopram is not effective, switching to another SSRI may be beneficial
   • Low-quality evidence showed no difference in remission when switching from one SSRI to another 1

Monitoring and Follow-up

• Monitor for suicidal ideation and behavior, especially during treatment changes
• Use standardized scales (PHQ-9 and GAD-7) to track progress
• Assess for side effects at each visit
• Regular follow-up every 2-4 weeks initially, then spacing out as symptoms improve

Important Considerations

• Avoid abrupt discontinuation: If medication changes are needed, taper escitalopram gradually to prevent discontinuation syndrome 2
• Self-harm risk: The history of self-harm on bupropion indicates a need for close monitoring and safety planning
• Drug interactions: Escitalopram has minimal drug interactions compared to other antidepressants 4
• Tolerability: Escitalopram is generally well-tolerated with fewer discontinuation symptoms compared to other antidepressants like paroxetine 5

Pitfalls to Avoid

1. Adding bupropion: Despite evidence that bupropion can be effective for anxiety 6 and can be combined with escitalopram 7, the patient's history of self-harm on this medication makes it contraindicated.

2. Increasing escitalopram beyond 20mg: Doses above 20mg are not recommended and may increase risk of QT prolongation 2.

3. Abrupt medication changes: Any medication changes should be done gradually to minimize withdrawal symptoms and potential worsening of anxiety or depression.

4. Underestimating the value of psychotherapy: CBT has shown comparable efficacy to medication for anxiety disorders and should be strongly considered as part of the treatment plan.