Are there any guidelines for the duration of maintenance on atypicals after response when used in conjunction with antidepressants for treatment of Major depression?

How long to continue treatment in a patient who has responded to therapy is one of the most difficult questions to answer for those of us who care for patients. A brief review of the most recent literature did not reveal studies that addressed the specific question of how long after treatment response to continue atypical antipsychotics when they are being used as augmentation with antidepressants for major depression. Given the absence of evidence, we recommend weighing the severity of the depressive symptoms that a given patient is experiencing against the side effect profile of the augmenting agent. With atypical antipsychotics, the risk for metabolic side effects is the most relevant concern to keep in mind while making this decision and monitoring of metabolic parameters should be performed when patients are taking these medications. One should also not assume that there is no risk of tardive dyskinesia with any of these agents with the possible exception of clozapine. Other potential long term sequale may be of particular concern given certain patient characteristics (e.g., age). Patient preference may be a deciding factor after discussion of the risk for potential worsening of depressive symptoms with premature discontinuation against the metabolic risk and related side effects of continuing the medication. A more ‘sustained’ period of remission may help long-term prognosis. Given the absence of evidence, however, there is no clear rule that can be given about these cases and the decision will vary greatly based on the clinical situation.

Curtis Wittmann, MD
MGH Academy Staff Psychiatrist