Using Antipsychotics as an Adjunctive Therapy in Depression

Following his Psych Congress 2019 presentation on drug combinations in major depressive disorder, Michael Thase, MD, discussed the use of second-generation antipsychotics as an adjunctive therapy in depression.

Dr. Thase is Professor of Psychiatry, Perelman School of Medicine, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.

Read the transcipt:

The two most commonly used adjunctive newer generation antipsychotics are aripiprazole and quetiapine.

Olanzapine has FDA approval in combination with fluoxetine but because of its metabolic issues, it's much less commonly used these days. Brexpiprazole is also FDA-approved but for pricing reasons it tends to sit on a lower tier, meaning that you often need to see generically available drugs not work before you can use it.

I prefer aripiprazole for patients who have low energy and for whom motivation is an issue. I prefer quetiapine for patients who are sleepless or with trouble sleeping, patients with a lot of anxiety.

It turns out these medicines work pretty well with most antidepressants. The only antidepressant I have some concern with combinations with is mirtazapine, which already has a lot of sedation, a lot of alpha inhibition and the possibility of already being appetite and weight-enhancing so that one I am less confident in safely using these medications together.

Most of the other serotonin reuptake inhibitors, or SNRIs, are pretty reasonable to combine with either quetiapine, aripiprazole or one of the other medicines when there's an indication for it.