Treatment-resistant depression: Are atypical antipsychotics effective and safe enough?
Adjunctive ‘atypicals’ may improve chronic unipolar depression; deciding when the benefits outweigh the risks is the clinical challenge.
SGAs probably belong ahead of electroconvulsive therapy or vagal nerve stimulation. But should they come before augmentation with lithium or thyroid hormone? Or, for that matter, trials of tricyclics or monoamine oxidase inhibitors?
Unfortunately, the available evidence provides little guidance. For a list of therapeutic algorithms developed for treatment-resistant depression, see Related resources.
Table 2
Recommended dosing of SGAs to augment antidepressant therapy
| Medication | Therapeutic range (mg/d) |
|---|---|
| Aripiprazole | 5 to 30 |
| Olanzapine | 5 to 20 |
| Quetiapine | 100 to 400 |
| Risperidone | 2 to 4 |
| Ziprasidone | 80 to 160 |
Algorithms for treatment-resistant depression
- Trivedi MH, Kern JK, Grannemann BD, et al. A computerized clinical decision support system as a means of implementing depression guidelines. Psychiatr Serv 2004;55(8);879-85.
- Rush AJ, Crismon ML, Kashner TM, et al. Texas Medication Algorithm Project, phase 3 (TMAP-3): rationale and study design. J Clin Psychiatry 2003;64(4);357-69.
- Trivedi M. Algorithms in clinical psychiatry: a stepped approach toward the path to recovery. Psychopharmacol Bull 2002;36(suppl 2);142-9.
- Trivedi MH, Kleiber BA. Algorithm for the treatment of chronic depression. J Clin Psychiatry 2001;62(suppl 6);22-9.
- Crismon ML, Trivedi M, Pigott TA, et al. The Texas Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Major Depressive Disorder. J Clin Psychiatry 1999;60(3);142-56.
- Aripiprazole • Abilify
- Bupropion • Wellbutrin
- Buspirone • BuSpar
- Citalopram • Celexa
- Clozapine • Clozaril
- Desipramine • Norpramin
- Duloxetine • Cymbalta
- Imipramine • Tofranil
- Lithium • various
- Nortriptyline • Pamelor
- Olanzapine • Zyprexa
- Olanzapine/fluoxetine • Symbyax
- Phenelzine • Nardil
- Pindolol • Visken
- Quetiapine • Seroquel
- Risperidone • Risperdal
- Selegiline (patch) • EMSAM
- Sertraline • Zoloft
- Tranylcypromine • Parnate
- Venlafaxine • Effexor
- Ziprasidone • Geodon
Dr. Shelton receives grant/research support from Eli Lilly and Co., GlaxoSmithKline, Pfizer, Janssen Pharmaceutica, sanofi-aventis, Wyeth Pharmaceuticals, AstraZeneca Pharmaceuticals, and Abbott Laboratories. He is a consultant to Pfizer and Janssen Pharmaceutica and a speaker for Bristol-Myers Squibb Co., Eli Lilly and Co., Janssen Pharmaceutica, Pfizer, GlaxoSmithKline, Solvay Pharmaceuticals, Wyeth Pharmaceuticals, and Abbott Laboratories.
