From the Guidelines
For a 53-year-old female with depression history currently taking fluoxetine 20mg and venlafaxine ER 150mg who still has significant depression (PHQ-9 score of 17), I strongly recommend continuing treatment for at least 4 to 9 months after achieving a satisfactory response, as suggested by the American College of Physicians 1. Given that the patient has not achieved an adequate response to the current pharmacotherapy, it is essential to reassess the treatment plan. The patient's current medication regimen includes fluoxetine 20mg and venlafaxine ER 150mg, which may not be sufficient to achieve optimal therapeutic effects. Considerations for optimizing the current medication regimen include:
- Increasing the dose of venlafaxine ER to 225mg daily, as therapeutic effects often require doses between 225-375mg daily
- Adding an adjunctive medication like bupropion XL 150mg daily, which can be increased to 300mg if needed, to target different neurotransmitter systems
- Augmentation with aripiprazole 2-5mg daily or switching to a different antidepressant class entirely, such as mirtazapine 15-30mg at bedtime It is crucial to note that the American College of Physicians recommends that clinicians continue treatment for 4 to 9 months after a satisfactory response in patients with a first episode of major depressive disorder, and an even longer duration of therapy may be beneficial for patients who have had 2 or more episodes of depression 1. Regular follow-up every 2-4 weeks is essential to monitor response and side effects, and these medication adjustments should be accompanied by psychotherapy if not already in place.
From the FDA Drug Label
In controlled trials used to support the efficacy of fluoxetine, patients were administered morning doses ranging from 20 to 80 mg/day. Studies comparing fluoxetine 20, 40, and 60 mg/day to placebo indicate that 20 mg/day is sufficient to obtain a satisfactory response in major depressive disorder in most cases A dose increase may be considered after several weeks if insufficient clinical improvement is observed. Doses above 20 mg/day may be administered on a once–a–day (morning) or BID schedule (i.e., morning and noon) and should not exceed a maximum dose of 80 mg/day.
The patient is currently on 20mg of fluoxetine and still experiencing depression problems. A dose increase may be considered after several weeks if insufficient clinical improvement is observed, as the patient has been on the current dose for an unspecified amount of time. The maximum dose of fluoxetine is 80mg/day, so increasing the dose to 40mg/day could be an option to consider, while monitoring for any potential side effects or interactions with other medications, such as venlafaxine 2.
From the Research
Patient Health Questionnaire (PHQ-9) Scores and Depression Treatment
- The patient's PHQ-9 score of 17 indicates moderate to severe depression 3, 4.
- A study found that a PHQ-9 score of 17 or higher at week 4 can predict a lack of response to treatment, suggesting that alternative treatment options may be necessary 3.
- Another study found that patients with a PHQ-9 score of 10 or higher had a mean of 2.1 follow-up PHQ-9 assessments in 12 months, indicating that the PHQ-9 is underutilized in monitoring depression treatment 5.
Treatment Outcomes and PHQ-9 Scores
- A study found that 41% of patients with a PHQ-9 score of 10 or higher responded to treatment at 12 weeks, and 45% responded at 24 weeks 4.
- The same study found that symptoms were in remission for 13% of patients at 12 weeks and 18% at 24 weeks, with severity of initial PHQ-9 score, weeks to first follow-up, and documented self-management predicting remission 4.
PHQ-9 as a Screening Tool
- The PHQ-9 has been identified as a reliable screening tool for depression, with a systematic review finding that it has been widely validated and recommended in a two-stage screening process 6.
- However, the review also noted that the accuracy of the PHQ-9 can vary depending on the cut-off score used, with a range of 5-15 used in different studies 6.
Clinical Use of the PHQ-9
- A study found that clinicians may influence the results of the PHQ-9 by how they present the response items, which can lead to either downgrading or upgrading the severity of depression 7.
- The study highlights the importance of considering the clinical context in which the PHQ-9 is used, and the potential for clinician-patient interactions to impact treatment decisions 7.