Atypical antipsychotics will be used more for treating depression
As a pharmacist, don't be surprised if you see atypical antipsychotics being used more often in treating depression. Both aripiprazole (Abilify) and olanzapine/fluoxetine (Symbyax) are already approved for resistant depression and quetiapine (Seroquel) will likely get a similar indication. More than half of patients with depression still have symptoms despite an adequate trial of an antidepressant. But DON'T be too quick to add an atypical antipsychotic...
First suggest counseling and change antidepressant regimens. For example, try switching from one antidepressant to another, or adding an antidepressant from a different class. If this isn't enough, consider augmenting antidepressants by adding another drug (lithium, thyroid, buspirone, antipsychotics, etc).
Atypical antipsychotics are especially useful for patients who also have bipolar or psychotic symptoms, but they can also be used for patients without psychotic symptoms. Keep in mind that atypical antipsychotics can cause more adverse metabolic effects (obesity, dyslipidemia, and hyperglycemia). There are also concerns about tardive dyskinesia and sudden cardiac death. Get our note, "Manage the side effects of antipsychotics".
Check weight, blood pressure, plasma glucose, and lipids at baseline, 12 weeks, and then at least annually. Recheck lipids in 5 years instead of yearly if lipids are normal and the patient is stable. Use aripiprazole (Abilify) if metabolic changes are a concern. It's less likely to cause problems than Seroquel or olanzapine (Symbyax, Zyprexa). On the other hand, use olanzapine or Seroquel if a more sedating drug is needed. Abilify can cause restlessness and insomnia.
References
- Berman RM, Marcus RN, Swanink R, McQuade RD, Carson WH, Corey-Lisle PK, Khan A. The efficacy and safety of aripiprazole as adjunctive therapy in major depressive disorder: a multicenter, randomized, double-blind, placebo-controlled study. J Clin Psychiatry. 2007 Jun;68(6):843-53.
- Trivedi MH, Thase ME, et al. An integrated analysis of olanzapine/fluoxetine combination in clinical trials of treatment-resistant depression. J Clin Psychiatry. 2009 Mar;70(3):387-96.
