What medication adjustments can be made for a patient with depression and ADHD, currently on fluoxetine 40 mg, trazodone 100 mg, and Adderall 20 mg extended release, to address worsening depressive symptoms without reducing Adderall dose?

Management of Depression in a 68-Year-Old Patient with ADHD

For a 68-year-old patient with worsening depression despite fluoxetine 40 mg, the most appropriate medication adjustment is to switch from fluoxetine to sertraline while maintaining the current Adderall and trazodone regimen.

Current Medication Assessment

The patient is currently on:

• Fluoxetine 40 mg daily (for depression, losing effectiveness after 5+ years)
• Adderall XR 20 mg daily (for ADHD, effective and patient wishes to continue)
• Trazodone 100 mg at bedtime (for sleep)

Recommended Medication Change

Primary Recommendation

1. Discontinue fluoxetine 40 mg and initiate sertraline
   • Start at 25-50 mg daily
   • Titrate to 50-200 mg daily based on response
   • Allow 4-6 weeks for full effect assessment

Rationale for Sertraline Selection

• The American College of Physicians recommends selecting second-generation antidepressants based on adverse effect profiles, cost, and patient preferences 1
• Sertraline has better efficacy for psychomotor agitation and melancholia compared to fluoxetine 2
• Sertraline has a more favorable side effect profile for older adults 1
• The patient's fluoxetine has been losing effectiveness after 5+ years of use

Maintain Current Medications

• Continue Adderall XR 20 mg daily as it has been helpful for ADHD symptoms
• Continue trazodone 100 mg at bedtime for sleep

Monitoring and Follow-up

1. Initial follow-up: Schedule within 1-2 weeks of medication change to assess for:

   • Emergence of suicidal thoughts (higher risk during medication transitions)
   • Adverse effects from sertraline
   • Withdrawal symptoms from fluoxetine

2. Efficacy assessment: Evaluate response at 4 weeks and 8 weeks

   • Target complete remission of depressive symptoms, not just partial improvement
   • Use standardized depression rating scales (e.g., PHQ-9 with target score ≤2)

3. Duration of treatment: Continue treatment for at least 4-9 months after satisfactory response 1

   • Since this is not the patient's first episode, longer maintenance treatment is recommended

Important Considerations

Cross-titration Approach

Due to fluoxetine's long half-life:

• Consider a brief washout period (3-5 days) before starting sertraline
• Start sertraline at a lower dose (25 mg) and gradually increase
• Monitor for serotonin syndrome during the transition period

Age-Related Factors

• Preferred antidepressants for older adults include sertraline, citalopram, escitalopram, mirtazapine, venlafaxine, and bupropion 1
• Fluoxetine should generally be avoided in older adults due to higher rates of adverse effects 1

Potential Pitfalls to Avoid

1. Avoid abrupt discontinuation of fluoxetine due to risk of withdrawal symptoms
2. Monitor for drug interactions between sertraline and Adderall (both can increase blood pressure)
3. Avoid paroxetine which has higher rates of sexual dysfunction and anticholinergic effects 1

Alternative Options if Sertraline is Ineffective

If sertraline does not provide adequate relief after 6-8 weeks at an optimal dose:

1. Consider bupropion augmentation:

   • Bupropion is FDA-approved for major depressive disorder 3
   • May complement the effects of sertraline with different mechanism of action
   • May be particularly helpful with ADHD symptoms

2. Consider venlafaxine:

   • SNRIs are slightly more likely than SSRIs to improve depression symptoms 1
   • However, they have higher rates of adverse effects like nausea and vomiting

The weekly therapy sessions you're arranging are an excellent complement to medication management and should be continued regardless of medication changes.