What are the evidence-based options for managing elevated depressed mood in a 60-year-old female patient with a complex medical history, including gastric sleeve surgery, chronic pain, and multiple medications, currently taking Wellbutrin (bupropion) 300mg IR and Lexapro (escitalopram) 20mg?

Management of Elevated Depressed Mood in a Patient with Complex Medical History

Increasing the Wellbutrin (bupropion) IR dose from 300mg to 348.5mg daily is the most appropriate evidence-based option for addressing this patient's elevated depressed mood, given her complex medical history and current medication regimen.

Assessment of Current Situation

This 60-year-old female patient presents with:

• Recent mood instability following medical complications (bowel obstruction, heart issues)
• Currently on bupropion 300mg IR and escitalopram 20mg
• Complex medical history including gastric sleeve surgery, chronic pain, and multiple medications
• Low motivation and decreased enjoyment at work
• No sleep issues reported
• Poor dietary habits

Evidence-Based Treatment Options

Option 1: Increase Bupropion Dose (Recommended)

• The American College of Physicians recommends selecting antidepressants based on adverse effect profiles, cost, and patient preferences 1
• Bupropion is effective for major depressive disorder and has a favorable side effect profile 2, 3
• Bupropion 348.5mg daily is equivalent to fluoxetine 40mg daily 4
• Advantages:
  • Less likely to cause sexual dysfunction compared to increasing escitalopram 1
  • May help with motivation and energy 2
  • Compatible with her gastric sleeve history (IR formulation already tolerated)
  • No significant drug interactions with her current medications

Option 2: Increase Escitalopram Dose (Not Recommended)

• Patient is already on escitalopram 20mg, which is at the higher end of the therapeutic range 5
• FDA label indicates limited additional benefit above 20mg with increased risk of side effects 5
• Escitalopram has potential for more drug interactions due to cytochrome P450 effects 6
• May worsen sexual dysfunction 1

Option 3: Switch or Add Another Antidepressant (Not First-Line)

• Switching medications would risk destabilizing the patient who had good control previously 6
• Adding another agent increases polypharmacy in a patient already on multiple medications

Implementation Plan

1. Increase bupropion IR from 300mg to 350mg daily

   • Maintain the IR formulation as patient needs to avoid XR formulations
   • Divide into multiple daily doses (e.g., 175mg twice daily)

2. Monitor for potential side effects:

   • Insomnia (administer earlier in the day)
   • Headache, dry mouth, nausea
   • Blood pressure changes (especially with metoprolol)
   • Seizure risk (though low at this dose)

3. Lifestyle modifications to complement pharmacotherapy:

   • Encourage return to healthier eating habits
   • Regular physical exercise to help with mood and energy
   • Stress management techniques given her recent medical stressors

Special Considerations for This Patient

• Gastric sleeve surgery: Bupropion IR is appropriate as the patient needs to avoid extended-release formulations 6
• Pain management: Bupropion does not significantly interact with oxycodone 6
• Cardiac issues: Monitor for any cardiovascular effects with the increased dose, especially given her metoprolol use
• Polypharmacy: Bupropion has fewer drug interactions than increasing escitalopram would 6

Follow-up Plan

• Reassess in 2-4 weeks to evaluate response and side effects
• Monitor blood pressure at each visit due to concurrent metoprolol
• If inadequate response after 6-8 weeks, consider alternative strategies such as augmentation with mirtazapine (which could also help with appetite) or referral to psychiatry for more specialized management

Caution

The American College of Physicians strongly recommends regular monitoring beginning within 1-2 weeks of medication changes, particularly for suicidal thoughts, agitation, irritability, or unusual behavior changes 1.