AUTHOR: Professor Philip Cowen
And this is probably because if you add something in, then you don’t lose the effects of the first treatment when you withdraw it as you might in a switch.
The problem with adding two drugs together is of course the side effect burden tends to be greater and the risk of interaction is there.
On the other hand, there’s a greater risk of side effects and drug interaction.
The same kind of effect seems to occur in patients taking SNRIs though this is not being studied so systematically.
So one is thinking of a dose of about 2.5 to 10 mg of aripiprazole, 50 to 300 mg of quetiapine.
Pharmacologically, 5-HT2 receptor blockade has been implicated.
So for a patient who is sleeping poorly with anxiety, adding quetiapine at night might be helpful.
Patients who seem to have more problems with motivation and anhedonia can be helped by the addition of aripiprazole.
So though this seems quite an effective strategy, there’s a high side effect burden. And in the controlled trials, the number needed to harm in terms of people dropping out of treatment was only about twice that of the number needed to treat.
So though this is a usual strategy, it’s not particularly well tolerated. And one has to look out for side effects such as sedation, weight gain with quetiapine, and movement disorders and anxiety with aripiprazole.
And that’s my experience that if you try and stop the atypical which is what you want to do, relatively quickly, patients will often relapse. So if you are going to withdraw the atypical eventually which is a very reasonable thing to do, go slowly and go carefully watching out for signs of relapse as you go.
I think where a patient has shown a partial response to an antidepressant, it can be better to augment with an atypical antipsychotic at that stage rather than switch. That’s because you don’t want to lose the effect, the partial response which you’ve already obtained with the antidepressant because the patient will feel worse.
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