Not long a go we discussed the need of antipsychotic for psychotic depression.
Use of antipsychotics for psychotic depression especially on the long term is not evidence based. It obscures diagnoses and treatment outcome leading to omission of other effective treatments in order to obtain remission for psychotic depression.
Recently a study was published on using an antipsychotic (risperidone) as addition to an antidepressant for nonpsychotic depression.
The study included 274 patients who had been depressed for nearly 17 years. The patients were first treated with various antidepressants: 60% were on a SSRI, 20% used venlafaxine and 15% on bupropion. The antidepressant were given for a period of four weeks. No patients experienced relief of symptoms. After these four weeks patients were given riperidone 1 mg/day or placebo. The dosage of risperidone could be increased to 2 mg/day after 4 weeks.
After 6 weeks 46% of patients responded in the risperidone group and 30% in the placebo group. Remission was obtained by 25% and 11% respectively.
The difference between mean score on the Hamilton Deression Rating Scale for the risperidone group and placebo group was only 1.9. The authors deemed 3 points clinical relevant.
If there is really an effect it is very small and clinically irrelevant. Moreover it means loosing time before using a more evidence based strategy such as lithium addition. Were looking forward for a comparison between risperidone, lithium and placebo.
Mahmoud RA, Pandina GJ, Turkoz I, Kosik-Gonzalez C, Canuso CM, Kujawa MJ, et al. Risperidone for Treatment-Refractory Major Depressive Disorder: A Randomized Trial. Ann Intern Med 2007;147(9):593-602.
See also for a critical discussion of these findings: Clinical Psychology and Psychiatry: A Closer Look