What is the next best treatment option for a patient with anxiety, depression, and possible Dissociative Identity Disorder (DID) who has failed to respond to Celexa (citalopram) and Cymbalta (duloxetine)?

Treatment Options for Anxiety, Depression, and Possible DID After Failed Trials of Citalopram and Duloxetine

For a patient with anxiety, depression, and possible DID who has failed trials of Celexa (citalopram) and Cymbalta (duloxetine), switching to bupropion or sertraline is recommended as the next best treatment option based on evidence from the STAR*D trial.

Medication Options After Failed Antidepressant Trials

First-Line Options

• Bupropion (Wellbutrin)

  • Particularly helpful for patients with fatigue, low energy, or sexual dysfunction 1
  • Starting dose: 100-150 mg daily, increasing by 100 mg every 5-7 days to maximum of 400 mg daily 1
  • Moderate-quality evidence shows no difference in response when switching from one antidepressant to bupropion 2
  • Lower risk of sexual dysfunction compared to other antidepressants 1
  • Caution: Avoid in patients with seizure disorders, eating disorders, or recent head trauma 1

• Sertraline (Zoloft)

  • Moderate-quality evidence shows no difference in response when switching from one antidepressant to sertraline 2
  • May be particularly beneficial for patients with anxiety symptoms 2
  • Better efficacy for managing melancholia and psychomotor agitation 2

Second-Line Options

• Venlafaxine (Effexor)

  • Recommended by American College of Physicians for SSRI non-responders 1
  • May be superior to fluoxetine for treating anxiety 2
  • More effective than citalopram in severely depressed patients (HAM-D21 score >31) 3
  • Two small studies showed greater response rates with venlafaxine than with other second-generation antidepressants 2

• Mirtazapine (Remeron)

  • Faster onset of action compared to SSRIs 2, 1
  • Beneficial for patients with insomnia or appetite issues 1
  • Acts on multiple receptor systems 1

Augmentation Strategies

If switching medications doesn't produce adequate response, consider these augmentation options:

• Bupropion augmentation

  • Low-quality evidence showed augmenting with bupropion decreases depression severity more than augmentation with buspirone 2
  • Moderate-quality evidence showed discontinuation due to adverse events was lower with bupropion than with buspirone 2

• Other augmentation options

  • Atypical antipsychotics, buspirone, stimulants, thyroid hormone, and lithium are potential augmentation strategies 4
  • Approximately 25% of patients become symptom-free after switching medications, even after multiple failures 1

Non-Pharmacological Approaches

• Cognitive Behavioral Therapy (CBT)

  • Low-quality evidence showed no difference in response or remission when switching from one antidepressant to cognitive therapy 2
  • Similar effectiveness to second-generation antidepressants with fewer adverse effects 1
  • Lower relapse rates compared to medication alone 1

• Other non-pharmacological options

  • Exercise therapy and physical activity can improve concentration 1
  • Sleep hygiene interventions may be beneficial 1

Monitoring and Assessment

• Begin monitoring 1-2 weeks after initiating new therapy 1
• Assess for:
  • Treatment response
  • Adverse effects
  • Vital signs
  • Suicidal thoughts
• Reassess concentration and cognitive status 2-4 weeks after medication changes 1

Special Considerations for DID

While specific evidence for treating DID with comorbid depression and anxiety is limited, the following considerations are important:

• Consistency in treatment approach is crucial
• Medication changes should be gradual to minimize destabilization
• Monitor for dissociative symptoms that may worsen with certain medications

Common Pitfalls to Avoid

• Inadequate dosing of the augmenting agent 1
• Premature discontinuation of treatment 1
• Failure to monitor for drug interactions 1
• Abrupt discontinuation of psychotropic medications 1

Treatment Algorithm

1. First attempt: Switch to bupropion or sertraline
2. If partial response: Consider dose optimization before moving to next step
3. If inadequate response after 4-6 weeks: Try venlafaxine or mirtazapine
4. If still inadequate: Consider augmentation strategies or adding CBT

Remember that approximately 38% of patients do not achieve a treatment response during 6-12 weeks of treatment with second-generation antidepressants, and 54% do not achieve remission 2. Persistence in finding the right medication or combination is essential.