Studies in the 1960s showed that Trilafon and Elavil were both effective in agitated depression, leading to their widespread use, including in the fixed combination Triavil (Trilafon + Elavil). When tardive dyskinesia and other motor side effects like acute dystonias were found to be caused by neuroleptics there was a retreat from using antipsychotics for anything but psychosis.

A recent study showing that agitation across diagnoses responded rapidly and with minimal side effects to sublingual asenapine in an emergency room setting is of interest.

Article A single-dose, randomized, double-blind, placebo-controlled ...

Dear Anthony, 

If you look for a very quick treatment for severely depressed it would be ECT. A round of ECT is effective for about 50% of people with treatment-resistant major depressive disorder, whether it is unipolar or bipolar.

Having recently rediscovered the work of Karl Jaspers, MD, I must point out that no two patients are the same and that while ideal types of depression, anxiety, psychosis are important conceptually, in clinical work each person is unique.

That said, YES! SOMETIMES CONTROLLING ANXIETY/AGITATION RAPIDLY is "just what the doctor ordered."

Attached find two papers, one about sublingual asenapine rapidly treating agitation in an ER setting, the other about intranasal ketamine rapidly treating the anguish of depression which leads to hope/less anxiety/return of hedonia/decrease in suicidality

Article A single-dose, randomized, double-blind, placebo-controlled ...

Article Ameliorating treatment-refractory depression with intranasal...

I agree with Margaret Hence: the first response need not be to rush to get a pill; in addition to breathing, there are a number of techniques used in Dialectical Behavioral Therapy, many of which go under the rubric "mindfulness", which can get one "centered" in ones own body in the here and now that can break the power of intolerable affects.

Attach find a paper I co-authored with Drs Anne-Marie Shelley, Joseph Battaglia, and Jeffrey Lucey on the impact of group CBT (as compared with standard group therapy) focusing on the five dimensions of psychopathology revealed by factor analysis of the PANSS; a paper on the "five factor" or pentagonal model is also attached.

Article Re: The Combined Use of Atypical Antipsychotics and Cognitiv...

Article Empirical assessment of the factorial structure of clinical ...

Margaret Hence's suggestion is ok with mild depression but I would argue, breathing exercises etc does not have any impact in cases of severe depression and does not answer my original question.  Is there anyone out there who thinks treating severe depression with antipsychotics as first choice as opposed to antidepressants is a valid argument?

Yes! Certainly not for everybody, but for persons with agitated depression, antipsychotics can be VERY effective.  The work of Hollister in the VAMC in the 1970s showed that perphenazine was effective.  More recent work by Pratts et al. (2014) found 10 mg of sublingual asenapine to be "just what the doctor ordered"

Article A single-dose, randomized, double-blind, placebo-controlled ...

There is no question that antipsychotics (AP) are very effective as augmentation of antidepressants (Nelson 2009, http://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2009.09030312)

and even alone in severe depression (with psychotic, anxious features, etc). In addition, per dr Opler's responses, there is evidence that they work alone as well. However, why not start as augmentation and capitalize on their quicker effect while at the same time starting antidepressant? Given the high risk of metabolic syndrome or TD- depending on the type of AP used-, the patient should eventually come off the APand remain on antidepressant for maintenance. So using AP buys time and decreases risk until antidepressant works, but likely not a good long term strategy.

It is often found essential for psychiatric progfessionals to completely develop an approprite scale to evaluate each individuals case as a fact find course of previous events leading to the present stages, and, serverity of clinical depression. The use of antipsychotics should not be taken lightly. The etiological bases are to be clearly identified, the rush to use antipsychotics should be a last resort associated with the discovered possibilities inherent to the patient's having to develop symptoms and conitinued issues of self-harm. The long term over exposure to such embolden efforts mat not prove to be productive for the well-being of an individual whose conditions may be associated with environmental unhappines or inherited factors attributed to the absolute certainity of the use of chemical therapuetic management for which may be enhanced by adverse EPS.  Significant to the apsect of a more effective treatment modality may involve the use of electro-convulsive shock therapy....and for future consideration, the use of a more compassionate form of treatment utilizing a depression scale to adjust to the use of contemporary treatment possibilites which may not  impact the lost of cognitive relativity.

The fundamental outcome for considering the application of the exploration of psychoanalytic-depression therapy may be assessed, and defined within a reasonable framework for maintaining a more humane level of efforts by which to guide the practice towards enabling the possibilites of addtional therapies for helping to resolve the issue. In final, although DBT, and similar therapeutic entities are efforts relative to consrtucting a possible path of adjunctive treatment, the reality is clear, the affective qualtity to control the condition relates to the degree, and the severity of the impression and the continued clinical manifistations which may leading to a sentinel event.

It is often found essential for psychiatric progfessionals to completely develop an approprite scale to evaluate each individuals case as a fact find course of previous events leading to the present stages, and, serverity of clinical depression. The use of antipsychotics should not be taken lightly. The etiological bases are to be clearly identified, the rush to use antipsychotics should be a last resort associated with the discovered possibilities inherent to the patient's having to develop symptoms and conitinued issues of self-harm. The long term over exposure to such embolden efforts mat not prove to be productive for the well-being of an individual whose conditions may be associated with environmental unhappines or inherited factors attributed to the absolute certainity of the use of chemical therapuetic management for which may be enhanced by adverse EPS.  Significant to the apsect of a more effective treatment modality may involve the use of electro-convulsive shock therapy....and for future consideration, the use of a more compassionate form of treatment utilizing a depression scale to adjust to the use of contemporary treatment possibilites which may not  impact the lost of cognitive relativity.

The fundamental outcome for considering the application of the exploration of psychoanalytic-depression therapy may be assessed, and defined within a reasonable framework for maintaining a more humane level of efforts by which to guide the practice towards enabling the possibilites of addtional therapies for helping to resolve the issue. In final, although DBT, and similar therapeutic entities are efforts relative to consrtucting a possible path of adjunctive treatment, the reality is clear, the affective qualtity to control the condition relates to the degree, and the severity of the impression and the continued clinical manifistations which may leading to a sentinel event.

I think there is always a rush to medicate people and I witnessed ECT given to people and it did not work but I am aware that it can be a life saver for some who have had an acute onset or have not had early intervention. Of course if it is simply a chemical imbalance then rush to the antipsychotics but I do believe that breathing exercises and a good regular interaction with a trusted person to carry out counselling in a safe space with relaxation exercises can help better than medicating. I think knowing the patient in front of you by a good engagement, and/or/as well as psychometric testing can only make the patient calm down and feel safe and understood.

Fair point but benzodiazepines are not good in terms of long time use. Arguably less risk with antipsychotics?

If the patient has psychotic symptoms , certainly yes; if not, quetiapine , which is both a mood stabilizer and has antidepressant activity, is a good choice. Also, it it prevents a switch to mania.

I agree Anthony. It is common practice among clinicians in my country. We see the severe cases, with late presentation and most with psychotic symptoms. Delaying the introduction of antipsychotics has often meant we lose the patient to follow-up, and they seek alternative treatment e.g. spiritual treatment or herbal concoctions.