Antipsychotic as Augmenting Agent in
Treatment of Major Depressive Disorder
University of Texas Rio Grand Valley
Patient Management Paper
Major depressive disorder
is a very prevalent chronic mental disorder. The prevalence of Major depressive
disorder is about 16 % throughout a person’s lifetime and about 7 % during a
1-year period. Major depressive disorder is the third leading cause of disability
impacting an individual’s life causes a high economic problem due to loss of
work days and a high suicide rate and vast impairment in quality of life, (Pae
The purpose of this paper
is to discuss about a patient who was diagnosed with major depressive disorder,
treatment resistant to antidepressants and achieved therapeutic outcome with
the use of antipsychotics, review of guidelines in using antipsychotic for
treatment resistant depression, plan of care for this patient with major depressive
disorder and teachings to patient and family to improve outcome and quality of
life with depression
of Treatment Guidelines and Evidence
Patient Miss B is a 53
y/o African American female who presented to the clinic with complain of lack
of motivation, lack of interest in pleasurable activities, poor energy, easily
irritable, mood swings, low self-esteem, poor energy, anxiety, frustration,
sleep disturbances for over 3 months. Patient have been diagnosed with
depressions since she was 30 years old and had been on and off treatment.
Patient was diagnosed with recurrent severe episodes of major depressive
disorder. Patient has had other trials of SSRI antidepressants, previous trials
include Wellbutrin xl 300mg, Paxil, Cymbalta and had an ineffective response to
treatment. The only medication she has responded to positively was Prozac. She
started on Prozac 20mg and currently on 60mg of Prozac, still medication did
not stabilized symptoms of depression as she reported anhedonia, lack of
motivation, anxiety low energy, easily frustrated, poor self-esteem, mood
swings and fatigued. Miss B also has a daughter who is suffering from mental
health illness bipolar disorder which worries her a lot and being overweight
which she is trying to lose weight. Abilify 2mg was added to treatment regimen
with positive changed. Since Abilify was added, patient depressive symptoms have
improved with medications, she is able to sleep, still reports feeling sad sometimes
not as she used to, still stressed due to her daughter dealing with bipolar, poor
self-esteem due to her weight she reported and frustration. she was also
recommended to begin psychotherapy.
Main treatment for Major
depressive disorder incudes selective serotonin reuptake inhibitors,
dopamine–norepinephrine reuptake inhibitors, serotonin– norepinephrine reuptake
inhibitors and noradrenergic and speci?c serotonin antagonists. Some of these
medications have been ineffective in treating major depressive disorder,
patients on antidepressants either have low response to treatment and relapse
if there was improvement in depressive symptoms. In 2007 the FDA approved
Abilify as an augmenting agent in treating major depressive disorder, pae&Patker,2013).
In addition, extended release Seroquel and olanzapine-fluoxetine is also
approved for treatment resistant depression. According to the American
Psychiatric A association guidelines.
providers should adjust treatment regime
based on a patient’s response and ability to tolerate side effects, (Llorca
According to the American
Psychiatric Association(APA) guidelines, treatment of Major depressive disorder
in the acute phase should aim at inducing remission and patient returning to
baseline. During an acute episode, treatment will include antidepressants and psychotherapy, (Pae,2013). According to the
APA guidelines, when a patient initially do not response to treatment with
antidepressants, patient diagnosis needs to be reappraised, assess treatment
adherence and side effects of medications, co-occurring conditions and reviewed
of psychosocial factors so that treatment can be adjusted, (Patker & Pae, 2013).
of care for Miss B with Major Depressive Disorder.
The World Health
Organization (WHO) defines quality of life (QOL) as an individual’s subjective
evaluation of physical, mental, and social domains. Major depressive disorder
(MDD), is the top cause of disability worldwide affecting closely to 350
million people, causes a significant deficit in quality of life. Importantly,
quality of life deficits usually persists past the clinical resolution of symptoms
placing patients at an increased risk for relapse and rising direct and
indirect costs (IsaHak et al, 2015).
The goal of treatment for
Miss B will be total remission and not relapsed. Since Miss B depressive
symptoms is improving, her diagnosis will be changed to Major depressive
disorder recurrent episodes in partial remission. This diagnosis is changed
because initially she had symptoms of depression and since treatment
augmentation she is not usually sad as she did before, easily irritable
sometimes, stressed and frustration not all the time and poor self-esteem
The treatment regime for
Miss B will be to continue with Prozac 60mg daily as ordered and Abilify 2mg
daily. Miss B will also be recommended to do psychotherapy at least twice a week.
I will also put Miss B on Topamax to help her with weight loss especially when
she is also taking Abilify. It was also recommended for Miss B to engaged in exercise,
limit carbohydrate intake, eat a lot of fruits and vegetables to help her loss
weight. Since Miss B is on antipsychotic, the following labs will be done
routinely every 3-6 months to monitor for metabolic imbalances, complete
metabolic panel, fasting glucose, and Lipid panel. Also every visit Miss B will
be access for suicide risk , the short and long term goal will ensure safety to
herself or others .I will also discussed risk and side effects of medications
so that Miss B is aware and will report any side effects immediately because
atypical antipsychotics can cause treatment-emergent adverse events (TEAEs),
which can be very burdensome and will usually
affect the quality of life and medication adherence .The treatment guidelines recommend that
physicians modify treatment regimens based on patients’ response and ability to
tolerate side effects, (IsHak et al, 2015).
and Family Teaching
Depression is a treatable
disorder that affects millions of people, from old to young and from all walks
of life. It affects an individual everyday life, resulting in pain, and affecting people around them. It
is important to educate family members about the basics of depression and not
to take a depressed individual’s behavior personal as it is a result of their
mental illness, (helpguide.org, 2017). Individuals with depression needs to
tell someone about their problems and not to hide it as it may keep them from
seeking treatment. Family members and friends should also be educated that they
do not have to be blame for someone else’s depression, it is in the hand of the
individual to want help or not, but at the same time should encouraged loved
ones to go get help. Friends can also support love ones by encouraging them to
engage in uplifting activities such as movies, exercise and dining out etc.
Also, they can volunteer to help with some of their chores or run errands for
them so that they do not feel burn out, be optimistic and above all be patient
with them. Doing all these will promote healing and improve quality of life.
In addition to love ones helping an
individual with depression improved their quality of life, individuals with
depression need to take care of themselves. Some of the ways to help themselves
include taking medications as prescribed, not skipping dose, keeping their
doctor and providers appointment, engaging in some form of exercise etc.
Patient can also get involved with support groups. long term online
peer-to-peer support group have been an effective intervention for reducing
depressive symptoms among members of the community with elevated depressive
symptoms and a self-reported history of depression, (Griffiths et al, 2012).
conclusion improving quality of life is an important treatment target for
patients with major depressive disorder, the presence of positive mental
health, such as optimism and self-confidence, a return to one’s usual, normal
self, and a return to normal levels of functioning at home, work, or school
helps patient achieved remission, (IsHak et al, 2015). Clinicians needs to
focus on areas where patients continue to have difficulties that impair healing
and improvement in quality of life. A lot of individuals with depression are
usually untreated or undertreated.
According to a study in the USA, it was found that
only about 21 % of individuals diagnosed with major depressive disorder had
received at least one form of American Psychiatric Association treatment
guideline-concordant therapy in the previous year, (Patker & Pae, 2013).
Griffiths, K. M., Mackinon, J., Crisp, D. A., Christensen,
H., Beneth, K., & Farrar, L. (2012). The Effectiveness of an Online Support
Group for Members of the Community with Depression: A Randomised Controlled Trial. PLos one,7(12). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3532446/
Helpguide.org (2017). Helping Someone with Depression.
Retrieved from https://www.helpguide.org/articles/depression/helping-someone-with-depression.htm
IsHak, W.W., Mirocha, J., James, D., Tobia, G.,
Vilhauer, J., Fakhry, H., Pi, S., Cohen, R. M. (2015). Quality of life in major depressive disorder before/after multiple
steps of treatment and one-year follow-up. Acta Psychiatric Scandinavica, 131:
Llorca, P., Lançon, C., Hartry, A., Michelle, B.,
Dana, B., François, C. (2017). Assessing the burden of treatment emergent
adverse events associated with atypical antipsychotic medications. Biomedical Central Psychiatry, 17:67.
Pae, C., & Patkar, A. A (2013). Clinical Issues in
Use of Atypical Antipsychotics for Depressed Patients. National Institute of Health, 27: S39–S45.
Patkar, A. A., & Pae, C. (2013).
Atypical Antipsychotic Augmentation Strategies in the Context of
Guideline-based Care for the Treatment of Major Depressive Disorder. National Institute of Health, 1: S29-37. Retrieved