Why did my doctor prescribe an antipsychotic for me when I am just depressed?

Antipsychotic medications are often prescribed for patients suffering from psychotic symptoms resulting from their depression. Such symptoms often revolve around false beliefs that the patient deserves some horrible punishment for a minor transgression that the patient believes to be a major sin or crime. Antipsychotics specifically target those symptoms, thus relieving patients of those painful thoughts and feelings. With the introduction of newer antipsychotic medications, however, their use as augmenting agents to antidepressants even in the absence of psychosis has become a new option for psychiatrists.

The newer antipsychotic medications, often called atypical antipsychotics^[1] or second-generation antipsychotics^[2] (SGAs), were developed because of increasing concern regarding the risk of developing a severe, potentially irreversible movement disorder known as tardive dyskinesia. Patients suffering from mood disorders are at greater risk for developing this movement disorder than patients who suffer primarily from psychotic disorders. SGAs have reduced this risk dramatically. They are, as a result, generally safer to use than their predecessors, although recently there have been growing concerns about their metabolic effects on the body, including the potential for weight gain, increased blood sugar, and increased cholesterol and lipids. Despite these concerns they remain an effective strategy when patients are showing only a partial response to their antidepressant medication or have a history of bipolar disorder and need medication to prevent the possibility of mania while undergoing treatment with an antidepressant medication.

SGAs include clozapine (Clozaril), quetiapine (Sero-quel), olanzapine (Zyprexa), risperidone (Risperdal), ziprasidone (Geodon), and aripiprazole (Abilify). The reason that SGAs appear to have a broader spectrum of effectiveness than their predecessors has to do with the multiple neurotransmitter effects these medications have, particularly on the neurotransmitter serotonin. As a result these medications appear to improve anxiety and insomnia, enhance attention and concentration, and provide some antidepressant as well as clear antimanic treatment and prevention. Psychiatrists use them for all these reasons, usually at doses lower than needed for psychotic symptoms. Most of these uses are off label, but, again, that does not mean they are experimental. Many studies support their use in this manner. Aripiprazole, however, now has an FDA indication for its use as an adjunct to an antidepressant for the treatment of depression and quetiapine an indication for its use in bipolar depression. It is important to remember that because a physician is prescribing an antipsychotic (or an antidepressant or anticonvulsant, etc.), he or she does not necessarily believe that you are psychotic (or depressed or suffering from epilepsy, etc.). It is always important to ask the physician about the rationale behind prescribing any medication.

How does generic medication differ from trade name medications?

The generic name of a medication is the international scientific name for the molecule that constitutes the active form of the medication. The company that develops the medication then applies for a patent and obtains exclusive rights to sell the medication. It then gives the medication a trade name, which can change from country to country and from its intended use. For example, the medication with the generic name paroxetine is marketed under the trade name Paxil in the United States and Seroxat in the United King dom. The medication with the generic name bupropion is used as an antidepressant under the trade

Are there differences between generic medications and medications under the trade name? The active ingredients of the medication are identical. The "fillers" or inactive ingredients making up the rest of the medication may differ.

name Wellbutrin and as a smoking cessation medication under the name Zyban. The medication with the generic name fluoxetine is used under the trade name Prozac as an antidepressant and as Sarafem, a medication prescribed by obstetricians for women suffering from premenstrual symptoms. Once a medication goes off patent, other companies obtain the right to make and sell it. At this point, generic forms of the medication that may be less expensive become available. These medications are sold under their generic names. As physicians first know the original form of the medication by its trade name, the physicians often continue to write prescriptions under that name. By law, pharmacies must fill the prescription with the less expensive form of the medication unless the physician specifically indicates to the pharmacy not to substitute. As a result, the filled prescription will come back to the patient under the generic name rather than the trade name.

Are there differences between generic medications and medications under the trade name? The active ingredients of the medication are identical. The "fillers" or inactive ingredients making up the rest of the medication may differ. There may also be more percentage variations between the amounts of active ingredients from pill to pill in generic medications than in trade medications, because the requirements for quantity control are more stringent with trade medications than with generic medications. These differences are so minute as to be negligible, and with repeated dosing the differences cancel each other. Patients have noticed differences initially in the way they feel when they switch from a trade to a generic medication, but this feeling is lost over time as the medication levels achieve a steady state in the person.

Are antidepressants prescribed for reasons other than depression?

The term "antidepressant" is actually a misnomer (see Question 59). Most psychoactive medications have multiple effects, and the decision to label a particular medication an antidepressant, an anticonvulsant, an antipsychotic, or an anxiolytic is often as much a matter of marketing as it is because of the drug's clinical effects. The newer class of antidepressants called SSRIs, for example, were originally developed and designed in the 1960s as potential antihypertensive medications. TCAs may have been marketed as antacids if not for the discovery of cimetidine (Tagamet), the first antihistamine antacid discovered.

Antidepressant medications have multiple properties that are used by different physicians to target specific symptoms with which their patients present. For example, neurologists have long been using TCAs to prevent migraine headaches, and endocrinologists have been using them to manage neuropathic pain^[3] associated with diabetes. Recently, rheumatologists have found success with SSRIs in treating the symptoms associated with fibromyalgia. One of the most effective medications to manage irritable bowel syndrome has been paroxetine. Aside from depression, the list of conditions that respond to antidepressant medications is fairly long. It includes most anxiety disorders but especially generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. However, antidepressant medications are also indicated in eating disorders as well as somatoform^[4] disorders. Internists use them extensively to treat insomnia, chronic pain disorders, and chronic fatigue syndrome. Obstetricians use them to manage dysmenorrhea and perimenopausal symptoms. Tables 11 and 12 list conditions that antidepressants can treat.

Table 11. Indications for the Use of Antidepressants

Table 12. Functional Somatic Syndromes

• [1] a second-generation antipsychotic with a profile of targeted brain receptors that differs from the older antipsychotics, which have fewer neurologic side effects and also have mood-stabilizing effects.
• [2] see atypical antipsychotic.
• [3] pain secondary to an abnormal state, such as degeneration, of nerves.
• [4] pertaining to conditions with physical symptoms thought to be due to psychological factors.