What medication adjustments are recommended for a patient with severe depression and anxiety on Abilify (aripiprazole) 15mg, duloxetine HCl (duloxetine) 60mg, and Vistaril (hydroxyzine) 50mg twice daily?

Medication Adjustment for Severe Depression and Anxiety

For a patient with severe depression and anxiety (10/10) with history of cutting who is currently on Abilify 15mg daily, duloxetine 60mg daily, and Vistaril 50mg twice daily, the most effective medication adjustment would be to increase the duloxetine dose to 120mg daily while maintaining the current Abilify dose.

Current Medication Analysis

1. Duloxetine (Cymbalta) 60mg daily

   • SSNRI with established efficacy for depression and anxiety
   • Current dose is at the lower end of the therapeutic range (40-120mg daily) 1
   • Patient still experiencing severe symptoms at this dose

2. Aripiprazole (Abilify) 15mg daily

   • Third-generation antipsychotic used as augmentation therapy
   • Effective as an augmentation agent for SSRI/SSNRI in treatment-resistant depression 2
   • Current dose is within therapeutic range (5-30mg daily) 1

3. Hydroxyzine (Vistaril) 50mg twice daily

   • Antihistamine used for short-term anxiety management
   • Not considered a primary treatment for major depression

Recommended Medication Adjustments

Step 1: Optimize Antidepressant Therapy

• Increase duloxetine to 120mg daily (60mg twice daily)
  • Duloxetine has a dose-dependent response with 120mg showing greater efficacy in severe depression 1
  • Higher doses are appropriate for patients with severe symptoms not responding to initial treatment

Step 2: Maintain Aripiprazole

• Continue Abilify at 15mg daily
  • Aripiprazole has shown effectiveness as an augmentation agent for patients with persistent depression and anxiety despite SSRI/SSNRI treatment 2
  • 59% of patients with treatment-resistant depression and anxiety showed significant improvement with aripiprazole augmentation at doses between 15-30mg daily 2

Step 3: Reassess Hydroxyzine

• Consider gradual tapering of Vistaril
  • While helpful for acute anxiety, it's not a primary treatment for depression
  • May contribute to sedation without addressing the underlying depression

Monitoring and Follow-up

• Schedule follow-up within 1-2 weeks after medication adjustment 1

  • Assess therapeutic response and adverse effects
  • Monitor for signs of increased suicidal ideation, particularly with history of self-harm

• If inadequate response after 6-8 weeks:

  • Consider alternative SSNRI (venlafaxine) or switching to a different class 1
  • Consider increasing aripiprazole dose up to 30mg if tolerated 2

Important Considerations

• Suicide risk monitoring: Patient with history of cutting requires close monitoring, especially during medication changes

• Duration of treatment: Continue treatment for at least 9-12 months after remission for first episode; longer for recurrent depression 1

• Potential side effects to monitor:

  • Duloxetine: Nausea, dizziness, dry mouth, increased blood pressure
  • Aripiprazole: Akathisia, weight gain, metabolic changes
  • Drug interaction: Monitor for serotonin syndrome with this combination

Treatment Rationale

The combination of an optimized SSNRI dose with aripiprazole augmentation has strong evidence for treatment-resistant depression with anxiety. Duloxetine at 120mg daily provides more robust antidepressant effects while maintaining the aripiprazole augmentation leverages its unique partial agonist properties at dopamine receptors, which can help address both depression and anxiety symptoms 3, 2.

This approach is supported by clinical guidelines recommending dose optimization of antidepressants before switching medications, and the established efficacy of aripiprazole augmentation in treatment-resistant depression 1.