Image of older man with cane, sitting alone

Older adults with severe depression have better outcomes when the antipsychotic aripiprazole (Abilify) is added to their existing antidepressant prescription versus a switch to bupropion, a new study has found.

Patients with depression are often unresponsive to initial drug treatment, according to the investigators. For example, only about 50% of elderly adults with major depressive disorder experience improvement of symptoms with antidepressants, according to a 2020 review and meta-analysis.

To help pinpoint the most effective options, clinicians often choose to try switching antidepressants, or will add on another class of drug. In the current study, investigators aimed to find evidence for using these approaches. To do so, they enrolled more than 700 adults aged 60 years or older with severe depression in a two-part trial. All were taking an antidepressant, such as Prozac, Lexapro or Zoloft, at baseline. 

Depression outcomes

The best overall outcomes were found in patients whose antidepressant prescription was augmented with aripiprazole. These study participants showed significant improvement in well-being over a 10-week period when compared with those whose original prescriptions were switched to the antidepressant bupropion (brand names Wellbutrin or Zyban). 

In addition, patients whose current prescriptions were augmented with either aripiprazole or bupropion appeared more likely to experience remission, the researchers noted. Remission occurred for 29% of patients in the aripiprazole-augmentation group and 28% in the bupropion-augmentation group, compared with 19% in the switch-to-bupropion group, they reported.

Investigators also monitored the rate of falls, a risk factor for older adults taking antidepressants and antipsychotics. Falls were higher in the group whose prescriptions were augmented with bupropion, they reported. 

Lithium and nortriptyline

The trial’s second step enrolled participants who were not helped by either augmentation or a switch to bupropion. Existing prescriptions were either augmented with lithium (a mood stabilizer) or were switched to the antidepressant nortriptyline. Remission in each case was approximately 15%, according to the researchers.

Clinicians caring for older adults with treatment-resistant depression may have better results with the antipsychotic add-on, they concluded.

Full findings were published in the New England Journal of Medicine.

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