Why Antipsychotics Are Underutilized for Major Depressive Disorder (MDD)

While not approved as monotherapies, clinicians may be overlooking the utility of antipsychotics as an adjunctive treatment for major depressive disorder (MDD), says Craig Chepke, MD, DFAPA, medical director, Excel Psychiatric Associates. 

Psych Congress Network sat down with Dr Chepke at the 2023 NP Institute in Boston to learn more about the bias both patients and clinicians may have against antipsychotic medications, the fear of potential side effects, and why serious illnesses call for "serious medications."

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Read the Transcript:

Craig Chepke, MD, DFAPA: Hi, I'm Dr. Craig Chepke. I'm a psychiatrist and the medical director of Excel Psychiatric Associates in Huntersville, North Carolina. I'm also an adjunct associate professor of psychiatry for Atrium Health, and I'm on the teering committee and the scientific advisor of Psych Congress.

During my session at NP Institute, “Antipsychotics and Mood Disorders,” I said something that might be thought of as a little bit controversial. I said that I don't think we use antipsychotics nearly as much in major depressive disorder as we probably should, and I still stand by that. We, I think, have a bias against antipsychotics and mood disorders. First off, we call them the wrong thing. We call them antipsychotics, and that's not what we're using them for. The same thing that patients worry about—patients tell me all the time that, "Oh, what, an antipsychotic? What do you think that I've got something wrong with me? I've got schizophrenia?" Things of that nature. No, it's also approved for major depressive disorder.

That's not just a patient bias. I think we, as clinicians, have that bias too, and it's rooted in fear, in fear of a lot of things. One is fear of the stigma of telling the patient that it's an antipsychotic, and having to do the little explanation that I just did about how well it's also approved for major depressive disorder and even further sometimes. But also a real true legitimate fear, which is a fear of potential side effects—weight gain, metabolic side effects, tardive dyskinesia.

Those are fears that are good. We want to be monitoring for those. We want to be cautious about those. We need to be weighing patients, checking their metabolic labs. We need to be screening for TD, not just with the formal assessments of the AIMS every 6 to 12 months, but with semiformal assessments every single time that we are seeing a patient on an antipsychotic. That fear is good, it keeps us in check, but we can't let that fear rule us.

Depression is a serious illness. Major depressive disorder is a serious illness. It is a life-threatening illness. And when there is a serious life-threatening illness, we need serious medications. The atypical antipsychotics, the 4 that are FDA-approved, are the most evidence-based treatments that we have.

I heard Dr Thase talk about in his session on antidepressants that he really, really wants bupropion to have the trials to show that it is effective as augmentation in major depressive disorder because he believes that it works. Well, like I said in my welcome session, “The Principles of Psychopharmacology,” a personal belief of something working is what allowed physicians to use bloodletting for 2,500 years until the field of statistics was born and people started counting and realized that it was not effective, was harming people.

So that's why it's so important to have the evidence. Of course, we can't use only evidence-based treatments, but when we do have highly evidence-based treatments, which the four approved atypical antipsychotics are in major depressive disorder, adjunct to an antidepressant, why would we not utilize those to the extent that they're appropriate? So that's why I think we need to reevaluate is that are we letting our own anxiety and our own fear stop us from using treatments that are going to be in our patient's best interest with the proper monitoring?

Craig Chepke, MD, DFAPA, is a Board-Certified psychiatrist and a Distinguished Fellow of the American Psychiatric Association. Dr Chepke is the medical director of Excel Psychiatric Associates in Huntersville, NC as well as an Adjunct Associate Professor of Psychiatry for Atrium Health. As part of an interdisciplinary treatment team, he employs a person-centered care model to tailor treatments to each individual's needs, integrating traditional pharmacotherapy with psychotherapeutic and physical health and wellness interventions.