Many people have seen the television ads for Abilify (aripiprazole) suggesting that you and your doctor consider adding it to your antidepressant to treat depression that has only partially responded to your antidepressant.
Abilify is a second-generation antipsychotic. It is used in the treatment of psychosis such as schizophrenia. What the manufacturer is suggesting is that it be used as an augmentation strategy for non-psychotic (regular) depression, by far the most common kind.
Everything discussed today about Abilify applies to all the other drugs like it, called the second generation anti-psychotics (SGAs). Other second-generation anti-psychotics are Zyprexa (olanzepin), Seroquel (quetiapine), and Risperdal (risperadone).
Augmentation is the addition of a second medicine to the patient’s antidepressant medicine. This is done in cases where the antidepressant clearly helps but the patient still has some depression symptoms while taking the maximum dose of the antidepressant.
Augmentation can be with another antidepressant from another antidepressant class except the monoamine oxidease inhibitors (MOAIs)–don’t add an MAOI. And I wouldn’t add an SSRI to an SNRI or an SNRI to an SSRI. See the TMAP Depression Manual (2008) for “the how to” on augmentation. See Texas Medication Algorithm Project Procedural Manual: Major Depressive Disorder Algorithm.
There are five different antidepressant classes: the selective serotonin reuptake inhibitors (SSRIs), the serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and the others class.
So, for example, if a patient is better but not completely better taking the maximum appropriate dose of sertraline (an SSRI), the doctor might recommend adding bupropion or mirtazapine (both are from the others class).
Or the doctor might recommend adding a non-antidepressant medicine such as lithium or liothyronine (T3, a specific thyroid hormone).
Or the doctor might reasonably recommend adding Abilify to augment the antidepressant. It does have an FDA indication for that use.
However, the 2010 American Psychiatric Association depression guidelines state on page 55:
“When compared with other strategies for antidepressant nonresponders, augmentation with second-generation antipsychotics carries disadvantages: the high cost of many agents, the significant risk of weight gain and other metabolic complications (e.g., dyslipidemia, hypertriglycermidemia, glucose dysregulation, diabetes mellitus), and potential risk of hyperprolactinemia, tardive dyskinesia, neuroleptic malignant syndrome, and QTc prolongation. Thus, the advantages and disadvantages of antipsychotic medicines should be considered when choosing this augmentation strategy. In addition, when augmentation with a second-generation antipscyhotic is effective, it is uncertain how long augmentation therapy should be maintained.”
Even considering the above, there may be times when a second generation antipsychotic (like Abilify) is an appropriate augmentation strategy.
In tomorrow’s post, I’ll go over guidelines for using second-generation antipsychotics in depression.