Antipsychotics for ordinary depression

"I'm taking an antidepressant, but I'm still not where I want to be with my symptoms."

If that line sounds familiar, it's because you might have heard it in recent television commercials for the powerful psychiatric drug aripiprazole (Abilify). Originally approved to treat the disabling mental illnesses of schizophrenia and bipolar disorder, Abilify is now, with permission from the Food and Drug Administration, being pitched to people with depression who haven't gotten relief from milder drugs such as SSRIs.

In December 2009, Abilify's competitor quetiapine (Seroquel XR) succeeded in winning the same approval as an add-on for depression.

The mass marketing of hard-core psychiatric drugs is worrisome, said Julie Donohue, Ph.D., an assistant professor at the University of Pittsburgh Graduate School of Public Health. "People might think from the commercial that everybody's going to get better, when really it's a minority of patients who respond to the treatment," she said.

Another issue is that the studies conducted to secure Abilify's approval as a depression add-on lasted only six weeks. "That means we don't know the long-term benefits or harms of the drug for this use, which is a problem because people will take Abilify for months—and probably years," said Steven Woloshin, M.D., a professor of medicine at Dartmouth Medical School.

Side effects include significant weight gain and elevated blood sugar. The drugs can also cause akathisia (inner restlessness or urge to move around), decreased white blood-cell counts, and rarely an irreversible condition called tardive dyskinesia that causes repetitive, involuntary movements of the face or body.

The ads tend to gloss over the fact that Abilify is just as likely to produce a bad side effect as it is to rid depression. In one of the six-week trials, depression went away in 25 percent of people taking Abilify, compared with 15 percent on a placebo. But 26 percent of the Abilify group experienced akathisia, compared with 4 percent of those on the placebo.

Something else the ads don't mention is the cost of the drugs: up to 45 times as much as many antidepressants.

Bottom line

The severe side effects associated with antipsychotics underscore the importance of considering them only as a last resort for hard-to-treat depression. Of the two antipsychotics approved as add-ons, Abilify appears to have fewer side effects than Seroquel.