From the Guidelines
For a 78-year-old female with depression who remains symptomatic on Effexor XR 225mg and Remeron 30mg, I would recommend adding a low-dose atypical antipsychotic such as aripiprazole (Abilify) 2-5mg daily or quetiapine (Seroquel) 25-50mg at bedtime as augmentation therapy, as this approach has shown efficacy in treatment-resistant depression by modulating dopamine and serotonin systems, while providing a different mechanism than her current serotonin-norepinephrine reuptake inhibitor (Effexor) and alpha-2 antagonist (Remeron) combination 1.
Key Considerations
- The patient's age and current medication regimen should be taken into account when making any changes, with a focus on minimizing side effects and maximizing efficacy.
- Before making medication changes, it's essential to reassess for medical conditions that might contribute to depression, such as thyroid dysfunction, vitamin deficiencies, or sleep apnea, and consider non-pharmacological approaches like psychotherapy.
- Close monitoring for side effects, including metabolic changes, sedation, and extrapyramidal symptoms, is crucial, particularly in elderly patients.
Alternative Options
- Switching one of her current medications to an SSRI like sertraline (Zoloft) 50-100mg daily or escitalopram (Lexapro) 10mg daily could be beneficial, as these medications have a different mechanism of action and may be effective in treating depression.
- Cognitive behavioral therapy (CBT) is also a viable option, as it has been shown to be effective in treating major depressive disorder, and can be used in conjunction with medication or as a standalone treatment 1.
Evidence-Based Recommendations
- The American College of Physicians recommends that clinicians select between either cognitive behavioral therapy or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient 1.
- The evidence suggests that augmentation with atypical antipsychotics can be an effective strategy for treatment-resistant depression, and that CBT and antidepressants are both viable choices for initial treatment of MDD 1.
From the Research
Medication Recommendations
The patient is currently on Effexor XR 225 (venlafaxine) and Remeron 30 (mirtazapine) but is still experiencing depression. Considering the current medication regimen, the following options can be explored:
- Adjusting the dose of venlafaxine, as the study 2 suggests that the lower range of the licensed dose (around 75-150 mg) may achieve optimal balance between efficacy, tolerability, and acceptability.
- Continuing the combination of venlafaxine and mirtazapine, as the study 3 found that 56% of patients responded to this combination at 6 months, with clinical response typically occurring at moderate and high dose treatment with both agents.
Considerations
When considering alternative medication options, it is essential to weigh the potential benefits and risks, including:
- Efficacy: The ability of the medication to reduce symptoms of depression.
- Tolerability: The likelihood of adverse effects, such as sedation and weight gain, which were common in the study 3.
- Acceptability: The patient's willingness to continue treatment, considering factors like dosage and potential side effects.
Dose Optimization
The study 2 provides guidance on optimal dosing for venlafaxine and mirtazapine:
- Venlafaxine: The dose-efficacy curve shows an initially increasing relationship up to around 75-150 mg, followed by a more modest increase.
- Mirtazapine: Efficacy increases up to a dose of about 30 mg and then decreases.