What alternative treatments can be considered for a patient with anxiety and mood issues who is currently on Wellbutrin (Bupropion) and Diazepam, and has previously tried Duloxetine, Prozac (Fluoxetine), and Lexapro (Escitalopram) with unfavorable side effects?

Alternative Treatments for Anxiety and Mood Issues

For a patient with anxiety and mood issues who has not responded to or tolerated multiple SSRIs, I recommend trying buspirone as the next treatment option, starting at 5mg twice daily and gradually titrating up to 30mg daily in divided doses.

Medication Options Analysis

Current Medication Assessment

• Patient is currently on:
  • Bupropion (Wellbutrin) - effective for depression but can potentially worsen anxiety 1
  • Diazepam - benzodiazepine with risk of dependence and tolerance

Previous Medication Trials

• Duloxetine (SNRI) - caused diarrhea
• Fluoxetine (SSRI) - ineffective
• Escitalopram (SSRI) - caused racing heart (tachycardia)

Recommended Medication Options

1. Buspirone (First Choice)

• Non-benzodiazepine anxiolytic with "anxioselective" properties 2
• Advantages:
  • Does not cause sedation or cognitive impairment 2
  • Low abuse potential and dependence risk 2
  • Can be used as an alternative to benzodiazepines 3
  • Effective for generalized anxiety disorder 4
  • Can be used as augmentation therapy 5
• Dosing:
  • Start at 5mg twice daily
  • Gradually increase to target dose of 15-30mg daily in divided doses 3
  • Maximum dose: 60mg daily 3

2. Sertraline (Alternative SSRI)

• Consider if buspirone is ineffective
• Has shown efficacy in both anxiety and depression 5
• Different side effect profile than previously tried SSRIs
• Start at lower dose (25mg) and titrate slowly to minimize side effects

3. Venlafaxine (SNRI Alternative)

• Effective for anxiety disorders with NNT = 4.94 5
• Different mechanism than duloxetine (previously tried SNRI)
• Starting dose: 37.5mg daily
• Maximum dose: 225mg daily 3

Non-Pharmacological Approaches

Cognitive Behavioral Therapy (CBT)

• Strongly recommended as first-line treatment for anxiety and depression 3
• Can be used alone or in combination with medication
• Optimal structure: 12-20 sessions 3
• Key components for anxiety:
  • Cognitive restructuring
  • Gradual exposure to feared situations
  • Relaxation techniques
  • Problem-solving skills 3

Treatment Algorithm

1. Add buspirone:

   • Start at 5mg twice daily
   • Increase by 5mg every 3-4 days as tolerated
   • Target dose: 15-30mg daily in divided doses
   • Allow 2-4 weeks for full effect

2. If inadequate response after 4-6 weeks:

   • Consider switching to sertraline (start at 25mg daily)
   • OR consider venlafaxine (start at 37.5mg daily)

3. Concurrent treatment:

   • Refer for CBT (12-20 sessions)
   • Consider gradually tapering diazepam once alternative treatment is effective

Monitoring and Follow-up

• Follow up within 1-2 weeks of medication changes 3
• Reassess symptoms every 2-4 weeks during medication adjustments 3
• Monitor for:
  • Treatment response
  • Side effects
  • Emergence of suicidal ideation (especially during medication transitions)

Important Considerations and Cautions

• Bupropion can worsen anxiety in some patients and has seizure risk at higher doses 1
• Bupropion inhibits CYP2D6 and can increase concentrations of many medications including venlafaxine, paroxetine, fluoxetine, and sertraline 1
• Avoid abrupt discontinuation of diazepam due to withdrawal risk
• Buspirone may take 1-2 weeks for onset of anxiolytic effect, so patient education about expectations is important 2

Practical Prescribing Tips

• If choosing buspirone, explain that unlike benzodiazepines, it may take 1-2 weeks to notice benefits 2
• If switching to sertraline or venlafaxine, start at lower doses than typically used for depression
• Consider drug interactions with bupropion if adding new medications 1
• Integrate CBT with medication management for optimal outcomes 3