Question: In adults with psychotic depression, for how long should antipsychotics be prescribed following remission of symptoms, in improving rates of relapse, readmission rates and physical and social functioning?

Answer:

One, short term, high quality RCT indicated that treatment with an antipsychotic in combination with an antidepressant may be more effective than treatment with an antidepressant alone, in achieving response and remission of depressive symptoms in hospitalised patients experiencing a major depressive episode with psychotic features.1 A follow-up study, which continued the same medication in those patients who had responded during the initial RCT, indicated that response was maintained and remission rates increased over four months in all treatment groups; there were no significant differences between the groups during follow-up, i.e. only the difference already observed during the RCT phase was preserved.2 There were two instances of relapse during the follow-up study, one in the imipramine group and one in the venlafaxine combined with quetiapine group.2 We were unable to identify any study which compared continuation of antipsychotic treatment with discontinuation for remission, relapse, re-admission rates or physical and social functioning. No study provided information on the optimum prescribing duration for antipsychotics as an augmentation to antidepressants.

More RCTs are needed to establish the optimum prescribing duration for antipsychotics as an augmentation to antidepressants; the limited evidence currently available indicates only that treatment effects can be maintained by continuation of the same treatment regimen, it provides no information on whether antipsychotics could be withdrawn after an initial treatment period without loss of effect. Additional studies are also needed to establish the relative effectiveness of other combined antidepressant and antipsychotic treatment options. Trials should also be conducted in a roader range of relevant populations; current evidence is limited to a hospitalised population experiencing an acute episode.