What can be added to the treatment regimen of an elderly female patient with a history of major depressive disorder (MDD) recurrent, brief psychotic disorder, and insomnia, who is currently on Wellbutrin (bupropion) 150mg and Zoloft (sertraline) 75mg, and is experiencing persistent visual hallucinations after a urinary tract infection (UTI)?

Management of Persistent Visual Hallucinations in Elderly Patient with MDD

Immediate Priority: Discontinue or Reduce Wellbutrin (Bupropion)

Bupropion significantly increases psychosis risk in elderly patients and should be tapered off or reduced, particularly given the presence of visual hallucinations following a medical stressor (UTI). 1

• Bupropion is a dopamine-norepinephrine reuptake inhibitor that can precipitate or worsen psychotic symptoms, especially in vulnerable elderly patients with a history of brief psychotic disorder 1
• The combination of bupropion with sertraline may be contributing to the persistent hallucinations through dopaminergic mechanisms 1
• Taper bupropion gradually over 1-2 weeks to avoid withdrawal symptoms while monitoring for worsening depression 1

Add Low-Dose Atypical Antipsychotic

Add a low-dose atypical antipsychotic (olanzapine 2.5-5 mg daily or quetiapine 25-50 mg daily) to address the persistent visual hallucinations, as combination antidepressant-antipsychotic therapy is the recommended treatment for depression with psychotic features in older adults. 2

• Practice guidelines recommend combining an antidepressant with an antipsychotic for major depression with psychotic features, yet only 5% of patients receive adequate combination therapy 2
• Olanzapine combined with sertraline has specific evidence in psychotic depression and is generally well tolerated in older adults 2
• Start with the lowest effective dose in elderly patients due to increased sensitivity to side effects and slower medication metabolism 3, 4

Optimize Sertraline Dosing

• Sertraline 75 mg is subtherapeutic for most patients with MDD; increase to 100-150 mg daily after adding the antipsychotic 5, 4
• Sertraline is the preferred SSRI in older adults due to favorable tolerability profile and lack of need for age-based dose adjustment 5, 4
• Allow 6-8 weeks at therapeutic doses before assessing full response 5

Address the Insomnia Component

• The insomnia may improve with treatment of the underlying depression and psychotic symptoms 6
• Avoid adding sedative-hypnotics initially; instead, use the sedating properties of low-dose quetiapine (25-50 mg at bedtime) if chosen as the antipsychotic, which addresses both hallucinations and insomnia 6
• Cognitive behavioral therapy for insomnia (CBT-I) is highly effective in older adults and should be considered as first-line non-pharmacologic treatment 6
• SSRIs like sertraline can cause or exacerbate insomnia in some patients; monitor for this effect 6

Critical Safety Monitoring

• Monitor closely for falls, as both antidepressants and antipsychotics increase fall risk in elderly patients 7
• SNRIs cause more overall adverse events than SSRIs in older adults, supporting the choice of sertraline over switching to an SNRI 7
• Screen for cognitive impairment, QTc prolongation, and orthostatic hypotension when initiating antipsychotic therapy 7
• Assess for treatment-emergent suicidality at 2 weeks, 4 weeks, and 8 weeks after medication changes 5

Rule Out Ongoing Medical Contributors

• Confirm UTI has fully resolved with repeat urinalysis if not already done
• Check for other delirium triggers: electrolyte abnormalities, medication interactions, new infections, or metabolic disturbances
• Review all medications for anticholinergic burden, which can cause visual hallucinations in elderly patients

Treatment Duration and Follow-up

• Continue combination antidepressant-antipsychotic therapy for minimum 4-9 months after symptom resolution for first episode, longer for recurrent depression 5, 4
• Reassess need for antipsychotic after 6-12 months of stability; may attempt gradual taper if hallucinations have fully resolved 2
• The longer duration of the current depressive episode is associated with need for more aggressive combination treatment 2

Common Pitfalls to Avoid

• Do not continue bupropion in a patient with active psychotic symptoms and history of brief psychotic disorder 1
• Do not use antidepressant monotherapy for depression with psychotic features; this approach has poor efficacy 2
• Do not use high-dose antipsychotics initially in elderly patients; start low and titrate slowly 4
• Do not add benzodiazepines for insomnia, as they increase fall risk and cognitive impairment in older adults 6