Expert: Ivan Goldberg, M.D. - 11/20/2005

Question
I was diagnoised as  having major depression and put on a combination 225 mg anafranil and 20 mg paxil due to my depression.I have been on these drugs for several weeks but they didn't work.So i went to another physciatrist and he added seroquel.(First week 25 mg then one week later 50 mg.)Can this be due to my having bipolar II disorder or its variant?Can i be also misdiagnoised by the first physciatrist?I read a lot about seroquel on internet so i'm confused now.(i have suicidal thoughts and states like derealization and depersoalization)

Thanks for your concern


Answer
Hi . . .

I have no idea what was in the mind of the psychiatrist who started you on Seroquel. While antipsychotics such as Seroquel are used to treat people with bipolar disorder, they are also used to potentiate antidepressants. Here are a few citations on that topic:

1: J Child Adolesc Psychopharmacol. 2005 Aug;15(4):696-702.

Adjunctive quetiapine for treatment-resistant adolescent major depressive
disorder: a case series.

Pathak S, Johns ES, Kowatch RA.

Children's Hospital Medical Center, Division of Child and Adolescent Psychiatry,
Cincinnati, Ohio 45229, USA. sanjeev.pathak@cchmc.org

BACKGROUND: Major depressive disorder (MDD) is a leading cause of disability and
mortality in adolescents. Empirical evidence suggests that many adolescents with
MDD do not respond or respond only partially to commonly used interventions
(antidepressants, psychotherapy, or a combination of antidepressants and
psychotherapy). There is preliminary data in adults that adjunctive
second-generation antipsychotics may be useful in treatment-resistant
depression. OBJECTIVE: The aim of this study was to obtain preliminary data
regarding the safety, tolerability, and clinical usefulness of quetiapine as
adjunctive therapy for adolescents (13-18 years of age) diagnosed with
treatment-resistant MDD. Treatment-resistant MDD was defined as a failure to
respond to an adequate dose for at least 8 weeks of a selective serotonin
reuptake inhibitor (SSRI). METHODS: The medical charts of 10 adolescents (13-18
years of age) diagnosed with treatment- resistant MDD, who were treated with
adjunctive quetiapine, were evaluated. Doses of preexisting antidepressants
remained unchanged during the period of evaluation. Response to treatment was
defined as a Clinical Global Impression-Improvement (CGI-I) score of 1 (very
much improved) or 2 (much improved). RESULTS: Seven adolescents (70%) qualified
as responders to treatment with adjunctive quetiapine. The median dose of
quetiapine was 200 mg (mean +/- SD = 275 +/- 190.4 mg, range; 150-800 mg). Side
effects included sedation (40%) and weight gain (mean +/- SD = 4.5 +/- 7.24
pounds). There was no serious adverse event. CONCLUSIONS: This case series
suggests that there may be a role for adjunctive quetiapine in
treatment-resistant adolescent depression. Clinical safety and efficacy trials
of quetiapine in this population appear to be warranted.

PMID: 16190801 [PubMed - in process]

2: J Clin Psychiatry. 2004 Jul;65(7):975-81.

The effectiveness of olanzapine, risperidone, quetiapine, and ziprasidone as

augmentation agents in treatment-resistant major depressive disorder.

Barbee JG, Conrad EJ, Jamhour NJ.

Department of Psychiatry, Louisiana State University Health Sciences Center, New
Orleans 70112, USA. jbarbe@lsuhsc.edu

BACKGROUND: Many questions remain regarding the use of atypical neuroleptics as
antidepressant augmentation agents. To date, there have been no reports in the
literature regarding the effectiveness of these drugs when trials of one or more
of them have failed previously as antidepressant augmentation. METHOD: This
retrospective chart review was conducted to determine the effectiveness of
olanzapine, risperidone, quetiapine, and ziprasidone when given in a
fee-for-service setting as anti-depressant augmentation agents to patients with
treatment-resistant, nonpsychotic major depressive disorder (DSM-IV).
Prospective (Global Assessment of Functioning [GAF]) along with retrospective
(Clinical Global Impressions-Improvement [CGI-I] and -Severity of Illness
scales) ratings were completed for each patient. Analyses were conducted in an
attempt to identify factors that appeared to correlate with response, including
order of administration and Thase-Rush staging of treatment resistance. RESULTS:
In this study of 76 medication trials in 49 patients, the overall response rate
based on the CGI-I ratings was 65% (32/49). Individual rates of response were
57% (21/37) for olanzapine, 50% (7/14) for risperidone, 33% (6/18) for
quetiapine, and 10% (1/10) for ziprasidone. None of the differences between
neuroleptics in rates of response were significant. The difference between
baseline and final GAF scores was statistically significant only in the
olanzapine (p <.001) and risperidone (p =.047) groups. Rates of discontinuation
did not vary significantly between agents, though trends were present. Crossover
trials from one atypical neuroleptic to another in the event of nonresponse
appeared to be effective. CONCLUSIONS: Although limited by its design, this
study suggests atypical neuroleptic augmentation of antidepressants may be a
viable option in treatment-resistant major depressive disorder.

PMID: 15291687 [PubMed - indexed for MEDLINE]

3: Ann Clin Psychiatry. 2004 Jan-Mar;16(1):3-13.

Atypical antipsychotics in the treatment of affective symptoms: a review.

Masan PS.

Department of Psychiatry, Duke University Medical Center, Durham, North Carolina
27702-3319, USA. masan001@mc.duke.edu

Atypical antipsychotics have demonstrated beneficial effects on affective
symptoms, in addition to antipsychotic activity. Consequently, their role in the
treatment of bipolar disorder and treatment-resistant or psychotic depression
has been explored. Adjunctive atypical antipsychotic therapy appears to benefit
patients experiencing manic episodes of bipolar disorder, and some studies
suggest that monotherapy may also be efficacious. Clinical studies of patients
with schizoaffective disorder and major depression support the use of atypical
antipsychotics to treat depression. This review focuses on risperidone,
olanzapine, quetiapine, and ziprasidone and provides evidence that these drugs
demonstrate activity against manic episodes of bipolar disorder when used as
adjunctive therapy and possibly as monotherapy and that depression in patients
with schizoaffective disorder also responds to these agents.

Publication Types:
   Review

PMID: 15147108 [PubMed - indexed for MEDLINE]

4: Seishin Shinkeigaku Zasshi. 2004;106(8):1025-9.

[Therapeutic and pharmacological effects of second-generation antipsychotics on
drug-resistant bipolar depression]

[Article in Japanese]

Kuroki T, Kaminiwa S, Haeno M, Kohara K, Ninomiya H.

Publication Types:
   Case Reports
   Review
   Review, Tutorial

PMID: 15655899 [PubMed - indexed for MEDLINE]

5: Curr Opin Investig Drugs. 2001 Jul;2(7):940-5.

Use of atypical antipsychotics in mood disorders.

Weizman R, Weizman A.

Tel Aviv Community Mental Health Center and Sackler Faculty of Medicine,
Tel-Aviv University, Israel.

Cumulative data indicate that atypical antipsychotics can serve as adjunctive as
well as alternative agents in the treatment of drug-resistant mood disorders.
Olanzapine and risperidone add-on treatment was found to be effective for major
depression with psychotic features and good results were achieved with currently
available atypical antipsychotics (clozapine, risperidone, olanzapine,
quetiapine and ziprasidone) in reducing symptoms of acute mania, especially when
added to mood stabilizers. The role of atypical antipsychotics in maintenance
and prophylactic treatment is not yet clear. Although there are differences in
the side effect profiles of the various atypical antipsychotics, their use is
limited by adverse effects such as extrapyramidal symptoms, weight gain,
somnolence and sexual dysfunction.

Publication Types:
   Review
   Review, Tutorial

PMID: 11757795 [PubMed - indexed for MEDLINE]

Best regards . . .

Ivan
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