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The Safety of Antipsychotics for Depression
Mary El Grammer
Medically reviewed on 11/23/2020 by
Dr. Kimberly Cress
Texas Regional Medical Director
Using antipsychotics for depression is one of the most common augmentation strategies for patients with treatment-resistant depression. Drugs such as Seroquel, Abilify, Rexulti, and Zyprexa are often prescribed when antidepressants don't work on their own, especially if a patient doesn't see relief from symptoms after two classes of medications. While these medications can be helpful, doctors and patients alike often underestimate the risks with this augmentation strategy. Atypical antipsychotics can be associated with problematic side effects and shrinking areas of the brain that house our neurons and neuron cell bodies. Is Transcranial Magnetic Stimulation (TMS) safe as an alternative to antipsychotics for depression?
Atypical Antipsychotic Risks and Benefits
One potential consequence of taking atypical antipsychotic medications is their metabolic effects. These drugs appear to increase insulin resistance, which can cause elevations in blood sugar and fat deposition, leading to weight gain. The weight gain can be quite substantial and can happen quickly, raising your risk of diabetes and high cholesterol. These medications can also contribute to motor problems like muscle stiffness, tremors, and even a permanent neurologic condition called tardive dyskinesia, which causes involuntary movements of the lips, mouth, and limbs.
What may be more alarming to some is the finding from a recent study that antipsychotics are associated with brain shrinkage, or what physicians call cortical atrophy, which can lead to cognitive deficiencies in memory and thinking. Brain shrinkage affects not just how you think through problems but also how you think about the world, limiting your ability to compose thoughtful observations, ideas, and arguments, thus potentially affecting your career, your relationships, or your parenting. Because of this, antipsychotics may be dangerous to take over the long term. While the potential side effects could deter you from trying atypical antipsychotics for depression, keep in mind that they have been proven to be beneficial over the short term and can be better than the consequences of untreated depression. Before you take an atypical antipsychotic, you should ask your doctor the following questions:
- Why are you choosing this particular atypical antipsychotic as opposed to another?
- What are the anticipated risks?
- What other treatment options are available to me?
Atypical antipsychotics are meant to help patients get better from treatment-resistant depression. But once you're in a state of recovery, you may be able to lower your dose and keep a close eye on your side effects, or come off of atypical antipsychotics altogether. If you're getting better with these medications, talk to your doctor about transitioning to other options for the treatment of major depression.
Beyond Atypical Antipsychotics: TMS and Other Options
If atypical antipsychotics aren't working for you as an augmentation strategy or if the side effects from these medications are causing too many health problems, you have many other options. For example, you can ask your doctor for a different atypical antipsychotic with fewer metabolic consequences. You can ask to try another augmentation strategy, like using Lithium, which doesn't have the same side effects. Evidence-based psychotherapy can help. Spravato, a nasal spray the Food and Drug Administration approved last year, is another effective treatment. Electroconvulsive therapy and vagus nerve stimulation are other options, but they're often reserved for patients who have tried many other therapies or those who are very ill.
Is TMS safe as another option? The answer might surprise you. A non-drug alternative for treatment-resistant depression that neither results in the side effects associated with atypical antipsychotics nor damages the brain, TMS may actually be associated with better brain health. Think of TMS like physical therapy for the brain—it enhances chemicals associated with increased brain complexity, and it may improve neuronal function over time. In observational trials, the response rate of TMS is upwards of 62 percent, which weighs favorably against any other strategy for treatment-resistant depression. The most important point here is to talk to your doctor about augmentation strategy options beyond atypical antipsychotics and the side effects that go hand in hand with them. If you would like to learn more about TMS therapy, you can set up a free consultation. Treatments are non-invasive, our centers are conveniently located, and we are providers on most insurance plans.
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Starting any medical treatment for the first time can leave you with questions, especially if you’re looking forward to the benefits it may bring. It’s no different when you’re preparing for your nasal esketamine treatment. Your previous mental health treatments may have consisted solely of taking antidepressants at home or visiting a therapist’s office for cognitive behavioral therapy (CBT), so nasal esketamine is probably a new treatment experience for you. If you're wondering what it's like to start nasal esketamine and get ready for your first session, keep reading. Getting Started with the Nasal Esketamine Treatment As with any new treatment, you’ll first talk to your primary care provider or psychiatrist about whether nasal esketamine is a good fit for you. Alternatively, you can schedule your esketamine nasal spray consultation with a treatment center (such as Greenbrook) that has certification by the FDA’s Risk Evaluation and Mitigation Strategy (REMS). At Greenbrook's REMS-certified nasal esketamine treatment centers, our Greenbrook-affiliated psychiatrists and psychiatric nurse practitioners will review your medical history and also conduct our own assessment to help determine whether nasal esketamine treatment is right for you. Certain conditions, including blood vessel disease and a history of psychosis, may make treatment a risk for you. Make sure you discuss all previous and present conditions with your doctor or nasal esketamine provider before beginning treatment. If the medication is deemed a good fit, you’ll receive your prescription from the Greenbrook-affiliated provider. Your Greenbrook Care Team will put together a personalized care plan for the weeks and months to follow. Keep in mind that you will need to take a standard (oral) antidepressant along with your nasal esketamine treatment. There are two important regulations to note when it comes to preparing for treatment: Each treatment is followed by a mandatory two-hour observation period. This means you will need to plan to stay at the center for at least two hours following your self-administration of the esketamine nasal spray. You cannot drive during the rest of the day after treatment and must arrange for transportation. These regulations are mandatory. It may be helpful to sit down and plan out several weeks’ worth of transportation once you know your treatment schedule. In addition, if you’re wondering what to bring for the treatment, we recommend entertainment such as an audiobook or playlist of favorite songs and a pair of headphones. You may want them during the two-hour observation period. What to Expect During Nasal Esketamine Treatment On the day of treatment, you’ll need to stop eating any food two hours before your appointment and stop drinking all fluids 30 minutes before you come in. Your Greenbrook Care Team will confirm that you are prepared for the two-hour observation period and that you have a ride home. You’ll get the opportunity to practice using a “trainer sprayer” that mimics the real nasal esketamine sprayer but does not release any medication. The Care Team will encourage you to use the restroom and set up your preferred environment in your private treatment bay or room. Some patients like reduced lighting, for example, while others don’t request light adjustments. You’ll complete a depression scale before each treatment session. Your Greenbrook provider will confirm that the dose kit is yours, show you how to administer it, and then hand it to you. Each sprayer contained 28mg of Spravato esketamine nasal spray. Patients usually start with two sprayers (56mg) and soon increase to 84mg (three sprayers) per treatment. But, your dosage maybe vary. Should you be left with a metallic taste by the spray, the Care Team will offer suckers to help make the flavor dissipate. After your dose, you’ll be encouraged to lie back in your comfortable recliner. While most patients enjoy a quiet setting, Greenbrook is prepared to accommodate patients with a more animated reaction to the medication. You may feel sleepy, dizzy, mildly dissociated, and/or nauseated during treatment. Greenbrook's Care Team is readily available if you need assistance. How to Prepare for after your Nasal Esketamine Treatment Most side effects begin to wane in the second hour of observation, but if you’re wondering, “Is it safe to drive immediately after nasal esketamine treatment?” the answer is a resounding no. In addition to the mandatory ride home, you will need to block off time to rest and let side effects fully dissipate. This extended rest period is especially important in the first weeks of treatment when you’ll have treatment twice a week. Do not drive or operate machinery of any kind until the day after treatment. Just take it easy, relax, and take care of yourself. If you’re unsure what activities you can do or should avoid during this time, talk to your Care Team for more information. While side effects tend to dissipate completely after a good night’s sleep, many nasal esketamine patients begin feeling relief from depression symptoms within hours of their treatment. Other Tips in Preparing for Your Nasal Esketamine Treatment At Greenbrook, we make every effort to schedule your treatment in the afternoons or whenever it is most convenient for you. We encourage you to see each treatment session as an opportunity to relax and take care of your mental health. If you have any questions or concerns, talk to your doctor or the Greenbrook Care Team. At Greenbrook, we’ll help you feel at ease when preparing for each treatment session. Schedule A Free Consultation To get started with nasal esketamine, schedule your free consultation today.
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