From the Guidelines
For a 42-year-old female with anxiety and depression who has not tolerated Lexapro, is allergic to Wellbutrin, found Buspar ineffective, couldn't tolerate Effexor, and is currently on Luvox, a good alternative to consider would be Sertraline (Zoloft). Sertraline is a preferred agent due to its favorable adverse effect profile, as noted in the study by 1. It works as an SSRI, which is a different mechanism than some of the medications previously tried, and has been shown to be effective in treating depression and anxiety. A typical starting dose would be 50mg taken once daily, which can be titrated up to 200mg as needed. Sertraline has the added benefit of helping with sleep and potentially increasing appetite, which can be beneficial if the patient has insomnia or weight loss associated with depression. It tends to have fewer sexual side effects and less nausea than some other SSRIs or SNRIs. When switching from Luvox to Sertraline, a cross-taper approach is recommended - gradually reducing Luvox over 1-2 weeks while starting Sertraline at 50mg, then adjusting the Sertraline dose as needed. Common side effects include nausea, headache, and insomnia. Regular follow-up within 2-4 weeks of starting the medication is important to assess response and manage any side effects, as recommended by 1. Some key points to consider when prescribing Sertraline include:
- Monitoring for suicidal thoughts and behaviors, especially in the first 1-2 months of treatment, as advised by 1
- Regularly assessing patient status, therapeutic response, and adverse effects of antidepressant therapy, as recommended by 1
- Considering the patient's preferences and cost of the medication when selecting a treatment option, as noted in 1
From the FDA Drug Label
Phenelzine sulfate should rarely be the first antidepressant drug used. Rather, it is more suitable for use with patients who have failed to respond to the drugs more commonly used for these conditions. The patient has already tried several common antidepressants (Lexapro, Wellbutrin, Buspar, Effexor) and is currently on Luvox.
- Phenelzine could be considered as an alternative due to the patient's history of mixed anxiety and depression, and failure to respond to other treatments 2.
- However, it's essential to exercise caution and carefully evaluate the patient's suitability for Phenelzine, given its potential side effects and interactions.
- A thorough assessment of the patient's medical history and current condition is necessary before making a decision to switch to Phenelzine.
From the Research
Alternative Treatment Options
The patient has a history of anxiety and depression, and has not tolerated or responded to various medications, including Lexapro, Wellbutrin, Buspar, and Effexor. Currently, the patient is on Luvox. Considering the patient's history, alternative treatment options may include:
- Cognitive-behavioral therapy (CBT) 3, 4
- Monoamine oxidase inhibitors (MAOIs) 5
- Selective serotonin reuptake inhibitors (SSRIs) 6
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) 6
- Tricyclic antidepressants (TCAs) 6
- Benzodiazepines (BDZs) 6
Efficacy of Alternative Treatments
Studies have shown that:
- CBT is an effective treatment for panic disorder and may be superior to applied relaxation and imipramine in the short-term 4
- MAOIs may be effective in treating atypical depression 5
- SSRIs, SNRIs, TCAs, and BDZs may be effective in treating panic disorder, with varying degrees of efficacy 6
- Augmenting with a second-generation antidepressant, an atypical antipsychotic, or lithium may be effective in managing treatment-resistant depression 7
Considerations for Switching Treatments
When switching treatments, it is essential to:
- Confirm adherence to adequate doses and duration of current medications 7
- Consider the patient's history of intolerance or non-response to previous medications
- Gradually withdraw the current medication, if necessary, to minimize withdrawal symptoms 4
- Monitor the patient's response to the new treatment and adjust as needed 7