From the Guidelines
For patients with major depressive disorder not fully responding to Lexapro 20mg and Buspar 7.5mg, I recommend adding an atypical antipsychotic such as aripiprazole (Abilify) at 2-5mg daily or quetiapine (Seroquel) 50-150mg at bedtime, as these medications have established efficacy as adjunctive treatments for depression, as suggested by various studies, including a systematic review funded by the Agency for Healthcare Research and Quality (AHRQ) 1.
When considering augmentation strategies for patients with major depressive disorder, it's essential to weigh the benefits and harms of different treatments. The evidence suggests that second-step therapies, including switching and augmentation strategies, provide similar symptom relief for patients not responding to initial treatment 1.
Some key points to consider when adding a new medication:
- Start at a low dose and gradually increase while monitoring for side effects and therapeutic response
- Allow 2-4 weeks to assess effectiveness before making further adjustments
- Consider the patient's preferences and potential side effects when choosing an adjunctive treatment
Alternative options for patients who cannot take Wellbutrin or prefer non-medication approaches include:
- Mirtazapine (Remeron) 15-30mg at bedtime, which works well with SSRIs and may help with sleep and appetite issues
- Cognitive behavioral therapy (CBT), which has been shown to be efficacious for MDD compared with placebo or other inactive interventions 1
- Transcranial magnetic stimulation (TMS), which may be beneficial for patients who have not responded to other treatments
It's crucial to prioritize the patient's quality of life, morbidity, and mortality when making treatment decisions, and to consider the most recent and highest-quality evidence available 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Major Depressive Disorder
- For patients with major depressive disorder who are not fully responding to Lexapro 20mg or Buspar 7.5mg, several treatment options can be considered, including switching to a different second-generation antidepressant or augmenting with a second pharmacologic treatment 2.
- Augmentation and adjunctive strategies involving atypical antipsychotics, as well as off-label options including buspirone, stimulants, thyroid hormone, and lithium, can also be reviewed 3.
Combination Therapy
- The combination of escitalopram and bupropion-SR has been shown to be effective and well-tolerated in patients with major depressive disorder who have had an inadequate response to antidepressant monotherapy 4.
- However, since the patient cannot take Wellbutrin, alternative combination therapies may need to be considered.
Selective Serotonin Reuptake Inhibitors (SSRIs)
- SSRIs, such as escitalopram, are commonly prescribed as a primary therapeutic intervention in major depressive disorder 5.
- Escitalopram has been shown to be more effective than other SSRIs in terms of response rate, remission rate, and withdrawal rate 5.
Personalized Treatment Approach
- The treatment approach should be personalized and based on discussion of potential treatment benefits, harms, adverse effect profiles, cost, feasibility, patients' specific symptoms, comorbidities, concomitant medication use, and patient preferences 2.