### instruction:
If you are a doctor, please answer the medical questions based on the patient's description.

### input:
I am a psychiatric/mental health ARNP consulting in LTC. 76 yowf with hx of alzheimers with depression and psychosis, copd, and pain. On Tramadol 25 mg BID; the notes available to me are from Feb 2014 forward. She has been on Tramadol since Feb; however, not certain site of pain or length of use prior to hospitalization. Hospitalized in Feb for exacerbation of COPD with pneumonia and has been on Prednisone since, has been titrated down to 5 mg for past 2 months. D/C from hospital to AFL with new behaviors of increased confusion, verbally agitated, wandering in and out of residents rooms, resistive to redirection. She had weight loss and problems sleeping and I started her on Remeron 15 mg HS and increased Seroquel. PCP added Cymbalta 20 mg in April. Once I saw that I d/c Remeron worried about serotonin symdrome. I am being told her delusions are causing her emotional pain with resulting behaviors more problematic. I will check with pulmonologist to see if Prednisone is going to be an ongoing med for COPD. MY QUESTION: drug/drug interaction with Tramadol: is REMERON safer than CYMBALTA; does one have less potential drug/drug interaction than the other when used in combination with Tramadol?

### output:

Hello thanks for asking from ChatDoctorI have read the query and I will try to solve it. She has history of Alzheimer's, Depression, Psychosis, COPD and is on Tramadol 50 mg per day, and was given Mirtazapine, Aquitaine for sleep. Now coming to question-- Mirtazapine and Duloxetine both increases serotonin and can interact with Tramadol but as per my opinion mirtazapine should be more safe and should have fewer interactions with Tramadol.- Both can Chat Doctor. Thanks, hope this helps you