Treating ‘depression’ in patients with schizophrenia

Antidepressants. If depressive symptoms persist after lowering or changing the antipsychotic, consider a trial of an adjunctive antidepressant. Titrate antidepressants to the recommended dose over 1 month, and continue antiparkinsonian medications. See patients frequently, and ensure that they receive psychosocial support.

No randomized trials have compared the efficacy of antidepressants for treating patients with schizophrenia; therefore, it is unclear if there is a preferred agent. Newer antidepressants often are used in depressed patients with schizophrenia because they are less likely to cause anticholinergic side effects. However, anticholinergic activity may be desirable, eg, for patients with akinesia. Caution is required when combining a selective serotonin reuptake inhibitor with clozapine because metabolism interactions could lead to toxic clozapine levels in some patients.¹⁹

If your patient’s depressive symptoms improve after adding an antidepressant, continue that agent along with the antipsychotic and any antiparkinsonian medications. Only 1 study has evaluated maintenance adjunctive antidepressant therapy for depressed patients with schizophrenia who initially responded to antidepressants. It found that imipramine appeared to protect patients from depressive relapse, and patients who received maintenance adjunctive imipramine were less likely to experience worsening psychotic symptoms.²⁰

Depressed schizophrenia patients are most likely to improve if they receive optimal psychosocial intervention,²¹ which consists of nonspecific support and, when indicated, psychosocial rehabilitation services. Change, even positive change, can be stressful, and patients with schizophrenia need every advantage they can get to be successful in moving their lives in a positive direction.

Related Resources

• Rybakowski JK, Vansteelandt K, Szafranski T, et al. Treatment of depression in first episode of schizophrenia: Results from EUFEST [published online ahead of print May 22, 2012]. Eur Neuropsychopharmacol. doi:10.1016/j.euroneuro.2012.04.001.
  
• Addington D, Addington J. Calgary Depression Scale for Schizophrenia. www.ucalgary.ca/cdss.
  

Drug Brand Names

• Benztropine • Cogentin
  
• Clozapine • Clozaril
  
• Fluphenazine • Permitil, Prolixin
  
• Haloperidol • Haldol
  
• Imipramine • Tofranil
  
• Olanzapine • Zyprexa
  
• Quetiapine • Seroquel
  
• Risperidone • Risperdal
  

Disclosure

Dr. Siris reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.