From the Guidelines
For a patient with anxiety and depression already taking fluoxetine, bupropion (Wellbutrin) is often a good medication to add, as it works differently by primarily affecting dopamine and norepinephrine rather than serotonin, which can help address symptoms that fluoxetine alone doesn't adequately control 1. A typical starting dose is 150 mg once daily of the extended-release formulation, which can be increased to 300 mg daily if needed after several weeks. This combination may be particularly helpful for patients experiencing persistent fatigue, low motivation, or concentration difficulties alongside their anxiety and depression. Some key points to consider when adding bupropion to fluoxetine include:
- Monitoring for serotonin syndrome, especially if considering mirtazapine or certain other antidepressants as adjuncts
- Starting with a low dose and gradually increasing as needed and tolerated
- Considering the patient's specific symptom profile, medical history, and previous medication responses when choosing between available options
- Regularly assessing patient status, therapeutic response, and adverse effects of antidepressant therapy, as recommended by the American College of Physicians 1. Another option is adding buspirone (BuSpar), typically starting at 7.5 mg twice daily and gradually increasing to 15-30 mg twice daily, which specifically targets anxiety symptoms and has minimal side effects or drug interactions with fluoxetine. However, bupropion is generally preferred due to its ability to address a broader range of symptoms, including fatigue and low motivation, which are commonly associated with depression and anxiety 1.
From the FDA Drug Label
The risk of using Prozac in combination with other CNS active drugs has not been systematically evaluated. Nonetheless, caution is advised if the concomitant administration of Prozac and such drugs is required In evaluating individual cases, consideration should be given to using lower initial doses of the concomitantly administered drugs, using conservative titration schedules, and monitoring of clinical status Serotonergic drugs — Based on the mechanism of action of SNRIs and SSRIs, including Prozac, and the potential for serotonin syndrome, caution is advised when Prozac is coadministered with other drugs that may affect the serotonergic neurotransmitter systems, such as triptans, linezolid (an antibiotic which is a reversible non–selective MAOI), lithium, tramadol, or St John’s Wort The concomitant use of Prozac with other SSRIs, SNRIs or tryptophan is not recommended
A good medication to add to fluoxetine for a patient with anxiety and depression is not explicitly stated in the label. Caution is advised when coadministering fluoxetine with other CNS active drugs or serotonergic drugs. Consideration should be given to using lower initial doses and conservative titration schedules, and monitoring of clinical status is recommended. The label does not provide a specific recommendation for a good medication to add to fluoxetine for a patient with anxiety and depression 2.
From the Research
Medication Options for Anxiety and Depression
When considering adding a medication to fluoxetine for a patient with anxiety and depression, several options can be explored.
- Clonazepam: A study 3 found that fluoxetine-clonazepam cotherapy may be beneficial for patients with anxious depression, with a larger advantage in remission rates compared to fluoxetine monotherapy.
- Other Antidepressants: Research 4 suggests that some antidepressants, such as sertraline, mirtazapine, and venlafaxine, may be more effective than fluoxetine for depression, but the clinical significance of these differences is uncertain.
- Selective Serotonin Reuptake Inhibitors (SSRIs): A systematic review 5 found that SSRIs, including fluoxetine, do not differ significantly in their effectiveness for treating accompanying anxiety, insomnia, and pain in patients with major depressive disorder.
Considerations for Treatment
When selecting a medication to add to fluoxetine, it is essential to consider the individual patient's symptoms, medical history, and potential side effects.
- Anxiety Symptoms: For patients with prominent anxiety symptoms, adding an anxiolytic medication like clonazepam may be beneficial.
- Depression Severity: For patients with more severe depression, an antidepressant with a stronger efficacy profile, such as sertraline or venlafaxine, may be considered.
- Side Effects and Tolerability: The tolerability and potential side effects of the added medication should be carefully evaluated, as some medications may have a better safety profile than others.