Pros and cons of prescribing potentially addictive medications for patients with refractory depression and anxiety

Abstract

Treatment resistant depression and refractory anxiety disorders are major mental health problems associated with a poor quality of life and a risk of suicide. These conditions require intensive biological treatments combined with psychosocial interventions. There are new treatments that are effective, particularly in the short run, but they are associated with negative effects such as risk of addiction. Ketamine produces fast improvement in treatment resistant depression (TRD), but effects are short-lasting and there is no sustained benefit. Oral formulations of ketamine are associated with a risk of addiction. No one has idea how long time oral or intranasal ketamine should be used. Stimulant augmentation may cause a significant reduction in some type of residual symptoms of depression but these improvements will disappear almost immediately after discontinuing stimulant medication. There is no consensus if a long-term use of stimulant medication, such as in ADHD, is acceptable in patients with treatment resistant depression. Treatment refractory anxiety disorders may not respond to SSRI/SNRIs as expected. Although a long-term use of benzodiazepines is not recommended, benzodiazepine augmentation is currently again supported. However, treatment effects usually disappear upon discontinuing BZDs. There is a common practice of using synthetic cannabinoid, nabilone for nightmares in PTSD. Long-term use of nabilone is unfortunately not uncommon. Some patients may even prefer a medical marijuana to get short improvements in their anxiety symptoms and depression. Physicians should be very cautious when prescribe medications with addictive potential particularly if there is no strong scientific evidence of their efficacy.