Abilify for depression?

I’ve written about this before — the expanded use of antipsychotic medication for indications other than psychosis. These run the gamut from acute mania, where a solid rationale exists, all the way to simple insomnia, for which there is no good rationale. Somewhere in between, but closer to the insomnia end of the scale, is the FDA-approved use of Abilify for unipolar depression.

When I first heard the atypical antipsychotic Abilify (aripiprazole) was being marketed by Bristol-Myers Squibb and Otsuka for depression, I shook my head in disbelief. (You can watch the tv ad on the official Abilify site here.) To its credit, the commercial recites the major, sometimes disabling or even lethal, side-effects, including neuroleptic malignant syndrome, irreversible tardive dyskinesia, dangerously high blood sugar, akathisia, etc, in a nice slow cadence rather than an auctioneer’s rapid-fire staccato. But nowhere is it mentioned that Abilify is an antipsychotic. Nor that antipsychotics are traditionally prescribed by specialists (psychiatrists), not primary-care providers, due to the unique and considerable risks of this class of drugs. The manufacturers paint a picture that looks like this: A depressed-but-functioning patient seeks help from a primary-care doctor, who prescribes an SSRI antidepressant like Prozac or Zoloft. It doesn’t help enough, so the MD adds Abilify and voila, success!

This is a dangerous scenario on several counts. First, in my opinion, primary-care doctors should not prescribe antipsychotics for psychiatric disorders, period. This is not to disparage the skills of internists and family practitioners who see common psychiatric presentations such as depression and anxiety on a regular basis, and know how to treat them. In fact, most antidepressants in the US are prescribed by primary-care MDs, not psychiatrists. But it is one thing to diagnose depression and prescribe a relatively safe antidepressant, and quite another to handle treatment-resistant cases, to distinguish among bipolar disorder, schizophrenia, organic psychotic states, severe personality disorders, etc, or to know the complex risks and benefits of various mood stabilizers and antipsychotics. These are jobs for a specialist. Can a primary-care doctor treat depression with an SSRI antidepressant, and maybe try a second one if the first doesn’t work? Sure. After that, I’d suggest referral to a psychiatrist.