Efficacy
of atypical neuroleptics in treatment-resistant
depression
Treatment-resistant
major depressive disorder is common and remains
an important problem for clinicians. Among the
available alternatives, the use of atypical
neuroleptics as antidepressant augmentation
agents seems to be an effective possibility.
However, the quality of clinical studies
examining their potential is questionable, and
thus the evidence of their efficacy is doubtful.
A systematic chart review of medication has been
conducted to determine the effectiveness of
olanzapine, risperidone, quetiapine, and
ziprasidone as antidepressant augmentation
agents in non-psychotic major depressive
disorder.
The response to atypical neuroleptic
augmentation was evaluated using the
retrospectively rated Clinical Global
Impressions-Improvement (CGI-I) and -Severity of
Illness scales. Prospectively rated Global
Assessment of Functioning (GAF) scores were also
completed for each patient. All patients
included in this study were started on treatment
with an atypical neuroleptic after being treated
with an antidepressant for at least 6 weeks. The
influence of order of neuroleptic administration
and Thase-Rush staging of treatment resistance
were the main factors that correlated with
response.
The study included 76 medication trials with 49
patients who had experienced treatment failure
with 8 antidepressants prior to beginning
atypical neuroleptic augmentation. The overall
response rate based on the CGI-I scores was 65%
(32/49). Individual response rates were 57% for
olanzapine, 50% for risperidone, 33% for
quetiapine, and 10% for ziprasidone. Response
rates betweeb drugs were not significantly
different. Differences between initial and final
GAF scores was significant only in the
olanzapine and risperidone groups. In the event
of non-response, crossover trials from one
neuroleptic to another were effective.
These findings show that by trying different
atypical neuroleptics, even though one does not
work it is quite likely that subsequent trials
with others will be successful. Clinicians
should apply this principle to treat resistant
depressed patients with atypical
antipsychotics. Barbee
JG, Conrad EJ, Jamhour NJ. The effectiveness of
olanzapine, risperidone, quetiapine, and
ziprasidone as augmentation agents in
treatment-resistant major depressive disorder. J
Clin Psychiatry 65: 975-81, 2004.