Psychiatric reference for writers: Medications used to help antidepressants work better

Sometimes an antidepressant alone aren’t enough to get depression under control.  Psychiatrists see this often: the patient has had a partial response to the medication (at an adequate dose over an adequate amount of time), but there’s definite room for improvement in the individual’s mood.  Treatment options at that point include switching the antidepressant to something else, adding a second antidepressant, or adding an augmenting agent to help jumpstart the first antidepressant.  Here is a partial list of augmenting medications. 

Thyroid hormone.  People who have too little thyroid hormone in their body have a tendency to feel depressed.  They are mentally and physically slowed.  It turns out that thyroid medication at low doses can help relieve these same symptoms in people without thyroid problems.  Thyroid hormone is also effective in treating bad mood swings.  Side effects can include anxiety, loss of appetite, dizziness, and sensitivity to heat.  Chest pain and osteoporosis are rare.

Stimulants.  Stimulants include amphetamines as well as wakefulness-promoting medications like Modafinil (Provigil).  Stimulantss are especially helpful in patients who sleep too much, have little energy, and exhibit slowed thinking/concentration problems.  They should be avoided in people with anxiety issues, as well as heart problems. Side effects can include high blood pressure, fast heart rate, weight loss, anxiety, fidgetiness, jerking movements, and poor sleep.  Some stimulants are addicting.  These medications are usually avoided in patients with substance abuse issues.

Lithium.  Typically used in bipolar disorder, Lithium exhibits an anti-depressant effect even in people who don’t have bipolar disorder.  The dose is typically much lower than one would use in people with bipolar disorder.  Side effects can include weight gain, shakes, problems during pregnancy, acne, diarrhea, thirst, excessive urination, and rarely thyroid and kidney problems.

Lamotrigine, or Lamictal.  Lamictal is often used in patients with bipolar depression.  It has been shown to be very helpful for depressed people without bipolar disorder, especially for those with mood swings.  The most concerning side effect is rare: a life-threatening rash.  It is important to start this medication at a low dose and increase it very slowly.

Atypical antipsychotics (AAP).  AAP’s can be helpful for depression, and some are FDA indicated for depression in people with only partial response to an antidepressant.  Examples include Quetiapine (Seroquel) and Aripiprazole (Abilify).  Some atypical antipsychotics exhibit antidepressant effects on their own, but they’re especially helpful when depression is accompanied by agitation, confused thinking, racing thoughts, insomnia, or hallucinations.  Side effects can include sleepiness or insomnia, weight gain, sugar or cholesterol problems, movement problems, and very seizures, heart problems, or coma.  Atypical antipsychotics should be used with care in patients with dementia.

Benzodiazepines (BZ).  BZ’s are helpful when depression presents with anxiety or insomnia.  Examples include Lorazepam (Ativan) and Clonazepam (Klonopin).  Side effects include sedation, loss of impulse control, and at high doses, breathing problems and coma.  These medications can be very addictive, so doctors try to avoid using them in people with substance abuse problems.  Usually BZ’s are used on a short-term basis.

Over-the-counter (OTC) augmentation strategies.  The major concern with OTC treatments include medication interactions and potential to worsen physical problems, especially if treatment isn’t discussed with the physician.  Some work directly on mood (SAM-E, 5-HTP, Omega-3 Fatty Acids).  Others target sleep or pain.

Alex Natalian is a pseudonym for psychiatrist KRR.

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