Psychotic depression

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Psychotic depression
Other namesDepressive psychosis
Grieving shadow.jpg
A drawing that attempts to capture the sadness, loneliness, and detachment from reality, as described by patients with psychotic depression
Specialty Psychiatry
Symptoms Hallucinations, delusions, anhedonia [1]
Complications Self-harm, Suicide
Usual onset20-40 years old
DurationDays to weeks, sometimes longer
Diagnostic method Clinical interview [2]
Differential diagnosis Schizoaffective disorder, schizophrenia, personality disorders, dissociative disorders
TreatmentMedication, cognitive behavioral therapy
Medication Anti-depressants, anti-psychotics

Psychotic depression, also known as depressive psychosis, is a major depressive episode that is accompanied by psychotic symptoms. [3] It can occur in the context of bipolar disorder or major depressive disorder. [3] It can be difficult to distinguish from schizoaffective disorder, a diagnosis that requires the presence of psychotic symptoms for at least two weeks without any mood symptoms present. [3] Unipolar psychotic depression requires that psychotic symptoms occur during severe depressive episodes, although residual psychotic symptoms may also be present in between episodes (e.g., during remission, mild depression, etc.). [4] [5] [6] [7] [8] [9] Diagnosis using the DSM-5 involves meeting the criteria for a major depressive episode, along with the criteria for "mood-congruent or mood-incongruent psychotic features" specifier. [10]

Contents

Signs and symptoms

Individuals with psychotic depression experience the symptoms of a major depressive episode, along with one or more psychotic symptoms, including delusions and/or hallucinations. [3] Delusions can be classified as mood congruent or incongruent, depending on whether or not the nature of the delusions is in keeping with the individual's mood state. [3] Common themes of mood congruent delusions include guilt, persecution, punishment, personal inadequacy, or disease. [11] Half of patients experience more than one kind of delusion. [3] Delusions occur without hallucinations in about one-half to two-thirds of patients with psychotic depression. [3] Hallucinations can be auditory, visual, olfactory (smell), or tactile (touch), and are congruent with delusional material. [3] Affect is sad, not flat. Severe anhedonia, loss of interest, and psychomotor retardation are typically present. [12]

Cause

Psychotic symptoms tend to develop after an individual has already had several episodes of depression without psychosis. [3] However, once psychotic symptoms have emerged, they tend to reappear with each future depressive episode. [3] The prognosis for psychotic depression is not considered to be as poor as for schizoaffective disorders or primary psychotic disorders. [3] Still, those who have experienced a depressive episode with psychotic features have an increased risk of relapse and suicide compared to those without psychotic features, and they tend to have more pronounced sleep abnormalities. [3] [11]

Family members of those who have experienced psychotic depression are at increased risk for both psychotic depression and schizophrenia. [3]

Most patients with psychotic depression report having an initial episode between the ages of 20 and 40. As with other depressive episodes, psychotic depression tends to be episodic, with symptoms lasting for a certain amount of time and then subsiding. While psychotic depression can be chronic (lasting more than 2 years), most depressive episodes last less than 24 months. A study conducted by Kathleen S. Bingham found that patients receiving appropriate treatment for psychotic depression went into "remission". They reported a quality of life similar to that of people without PD. [13]

Pathophysiology

There are a number of biological features that may distinguish psychotic depression from non-psychotic depression. The most significant difference may be the presence of an abnormality in the hypothalamic pituitary adrenal axis (HPA). The HPA axis appears to be dysregulated in psychotic depression, with dexamethasone suppression tests demonstrating higher levels of cortisol following dexamethasone administration (i.e. lower cortisol suppression). [3] Those with psychotic depression also have higher ventricular-brain ratios than those with non-psychotic depression. [3]

Diagnosis

Differential diagnosis

Psychotic symptoms are often missed in psychotic depression, either because patients do not think their symptoms are abnormal or they attempt to conceal their symptoms from others. [3] On the other hand, psychotic depression may be confused with schizoaffective disorder. [3] Due to overlapping symptoms, differential diagnosis includes also dissociative disorders. [14]

Treatment

Several treatment guidelines recommend pharmaceutical treatments that include either the combination of a second-generation antidepressant and atypical antipsychotic or tricyclic antidepressant monotherapy or electroconvulsive therapy (ECT) as the first-line treatment for unipolar psychotic depression. [15] [16] [17] [18]

There is no evidence for or against the use of mifepristone. [19]

Combined antidepressant and antipsychotic medications

There is some evidence indicating that combination therapy with an antidepressant plus an antipsychotic is more effective in treating psychotic depression than either antidepressant treatment alone or placebo. [19] In the context of psychotic depression, the following are the most well-studied antidepressant/antipsychotic combinations:

First-generation

Second-generation

Antidepressant medications

There is insufficient evidence to determine if treatment with an antidepressant alone is effective. [19] Tricyclic antidepressants may be particularly dangerous, because overdosing has the potential to cause fatal cardiac arrhythmias. [16]

Antipsychotic medications

There is insufficient evidence to determine if treatment with antipsychotic medications alone is effective. [19] Olanzapine may be an effective monotherapy in psychotic depression, [25] although there is evidence that it is ineffective for depressive symptoms as a monotherapy; [16] [23] and olanzapine/fluoxetine is more effective. [16] [23] Quetiapine monotherapy may be particularly helpful in psychotic depression since it has both antidepressant and antipsychotic effects and a reasonable tolerability profile compared to other atypical antipsychotics. [26] [27] [28] The current drug-based treatments of psychotic depression are reasonably effective but can cause side effects, such as nausea, headaches, dizziness, and weight gain. [29]

Electroconvulsive therapy

In modern practice of ECT a therapeutic clonic seizure is induced by electric current via electrodes placed on a person under general anesthesia. Despite much research the exact mechanism of action of ECT is still not known. [30] ECT carries the risk of temporary cognitive deficits (e.g., confusion, memory problems), in addition to the burden of repeated exposures to general anesthesia. [31]

Research

Efforts are made to find a treatment which targets the proposed specific underlying pathophysiology of psychotic depression. A promising candidate was mifepristone, [32] which by competitively blocking certain neuro-receptors, renders cortisol less able to directly act on the brain and was thought to therefore correct an overactive HPA axis. However, a Phase III clinical trial, which investigated the use of mifepristone in PMD, was terminated early due to lack of efficacy. [33]

Transcranial magnetic stimulation (TMS) is being investigated as an alternative to ECT in the treatment of depression. TMS involves the administration of a focused electromagnetic field to the cortex to stimulate specific nerve pathways.

Research has shown that psychotic depression differs from non-psychotic depression in a number of ways: [34] potential precipitating factors, [35] [36] [37] underlying biology, [38] [39] [40] [41] symptomatology beyond psychotic symptoms, [42] [43] long-term prognosis, [44] [45] and responsiveness to psychopharmacological treatment and ECT. [46]

Prognosis

The long-term outcome for psychotic depression is generally poorer than for non-psychotic depression. [16]

Related Research Articles

<span class="mw-page-title-main">Antipsychotic</span> Class of medications

Antipsychotics, previously known as neuroleptics and major tranquilizers, are a class of psychotropic medication primarily used to manage psychosis, principally in schizophrenia but also in a range of other psychotic disorders. They are also the mainstay, together with mood stabilizers, in the treatment of bipolar disorder. Moreover, they are also used as adjuncts in the treatment of treatment-resistant major depressive disorder.

<span class="mw-page-title-main">Bipolar disorder</span> Mental disorder that causes periods of depression and abnormally elevated mood

Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks. If the elevated mood is severe or associated with psychosis, it is called mania; if it is less severe, it is called hypomania. During mania, an individual behaves or feels abnormally energetic, happy or irritable, and they often make impulsive decisions with little regard for the consequences. There is usually also a reduced need for sleep during manic phases. During periods of depression, the individual may experience crying and have a negative outlook on life and poor eye contact with others. The risk of suicide is high; over a period of 20 years, 6% of those with bipolar disorder died by suicide, while 30–40% engaged in self-harm. Other mental health issues, such as anxiety disorders and substance use disorders, are commonly associated with bipolar disorder.

Bipolar I disorder is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other times, have one or more depressive episodes.

<span class="mw-page-title-main">Major depressive disorder</span> Mental disorder involving persistent low mood, low self-esteem, and loss of interest

Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introduced by a group of US clinicians in the mid-1970s, the term was adopted by the American Psychiatric Association for this symptom cluster under mood disorders in the 1980 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and has become widely used since.

Mania, also known as manic syndrome, is a mental and behavioral disorder defined as a state of abnormally elevated arousal, affect, and energy level, or "a state of heightened overall activation with enhanced affective expression together with lability of affect." During a manic episode, an individual will experience rapidly changing emotions and moods, highly influenced by surrounding stimuli. Although mania is often conceived as a "mirror image" to depression, the heightened mood can be either euphoric or dysphoric. As the mania intensifies, irritability can be more pronounced and result in anxiety or anger.

<span class="mw-page-title-main">Mood stabilizer</span> Psychiatric medication used to treat mood disorders

A mood stabilizer is a psychiatric medication used to treat mood disorders characterized by intense and sustained mood shifts, such as bipolar disorder and the bipolar type of schizoaffective disorder.

<span class="mw-page-title-main">Atypical antipsychotic</span> Class of pharmaceutical drugs

The atypical antipsychotics (AAP), also known as second generation antipsychotics (SGAs) and serotonin–dopamine antagonists (SDAs), are a group of antipsychotic drugs largely introduced after the 1970s and used to treat psychiatric conditions. Some atypical antipsychotics have received regulatory approval for schizophrenia, bipolar disorder, irritability in autism, and as an adjunct in major depressive disorder.

<span class="mw-page-title-main">Quetiapine</span> Atypical antipsychotic medication

Quetiapine, sold under the brand name Seroquel among others, is an atypical antipsychotic medication used for the treatment of schizophrenia, bipolar disorder, and major depressive disorder. Despite being widely used as a sleep aid due to its sedating effect, the benefits of such use may not outweigh its undesirable side effects. It is taken orally.

<span class="mw-page-title-main">Olanzapine</span> Atypical antipsychotic medication

Olanzapine, sold under the brand name Zyprexa among others, is an atypical antipsychotic primarily used to treat schizophrenia and bipolar disorder. For schizophrenia, it can be used for both new-onset disease and long-term maintenance. It is taken by mouth or by injection into a muscle.

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses.

Biological psychiatry or biopsychiatry is an approach to psychiatry that aims to understand mental disorder in terms of the biological function of the nervous system. It is interdisciplinary in its approach and draws on sciences such as neuroscience, psychopharmacology, biochemistry, genetics, epigenetics and physiology to investigate the biological bases of behavior and psychopathology. Biopsychiatry is the branch of medicine which deals with the study of the biological function of the nervous system in mental disorders.

<span class="mw-page-title-main">Mixed affective state</span> Medical condition

A mixed affective state, formerly known as a mixed-manic or mixed episode, has been defined as a state wherein features and symptoms unique to both depression and (hypo)mania, including episodes of anguish, despair, self doubt, rage, excessive impulsivity and suicidal ideation, sensory overload, racing thoughts, heightened irritability, decreased "need" for sleep and other symptoms of depressive and manic states occur either simultaneously or in very short succession.

Treatment-resistant depression is a term used in psychiatry to describe people with major depressive disorder (MDD) who do not respond adequately to a course of appropriate antidepressant medication within a certain time. Definitions of treatment-resistant depression vary, and they do not include a resistance to psychological therapies. Inadequate response has most commonly been defined as less than 50% reduction in depressive symptoms following treatment with at least one antidepressant medication, although definitions vary widely. Some other factors that may contribute to inadequate treatment are: a history of repeated or severe adverse childhood experiences, early discontinuation of treatment, insufficient dosage of medication, patient noncompliance, misdiagnosis, cognitive impairment, low income and other socio-economic variables, and concurrent medical conditions, including comorbid psychiatric disorders. Cases of treatment-resistant depression may also be referred to by which medications people with treatment-resistant depression are resistant to. In treatment-resistant depression adding further treatments such as psychotherapy, lithium, or aripiprazole is weakly supported as of 2019.

The emphasis of the treatment of bipolar disorder is on effective management of the long-term course of the illness, which can involve treatment of emergent symptoms. Treatment methods include pharmacological and psychological techniques.

<span class="mw-page-title-main">Olanzapine/fluoxetine</span> Antidepressant medication

Olanzapine/fluoxetine is a fixed-dose combination medication containing olanzapine (Zyprexa), an atypical antipsychotic, and fluoxetine (Prozac), a selective serotonin reuptake inhibitor (SSRI). Olanzapine/fluoxetine is primarily used to treat the depressive episodes of bipolar I disorder as well as treatment-resistant depression.

Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder (BP-I).

<span class="mw-page-title-main">Lurasidone</span> Atypical antipsychotic medication

Lurasidone, sold under the trade name Latuda among others, is an antipsychotic medication used to treat schizophrenia and bipolar disorder. It is taken by mouth.

Post-schizophrenic depression is a "depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present." Someone that has post-schizophrenic depression experiences both symptoms of depression and can also continue showing mild symptoms of schizophrenia. Unfortunately, depression is a common symptom found in patients with schizophrenia and can fly under the radar for years before others become aware of its presence in a patient. However, very little research has been done on the subject, meaning there are few answers to how it should be systematically diagnosed, treated, or what course the illness will take. Some scientists would entirely deny the existence of post-schizophrenic depression, insisting it is a phase in schizophrenia as a whole. As of late, post-schizophrenic depression has become officially recognized as a syndrome and is considered a sub-type of schizophrenia.

<span class="mw-page-title-main">Melancholic depression</span> Medical condition

Melancholic depression, or depression with melancholic features, is a DSM-IV and DSM-5 specifier of depressive disorders. The specifier is used to distinguish clinically relevant subsets of causes and symptoms that have the potential to influence treatment.

References

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  2. ↑ Dubovsky, Steven L.; Ghosh, Biswarup M.; Serotte, Jordan C.; Cranwell, Victoria (2021). "Psychotic Depression: Diagnosis, Differential Diagnosis, and Treatment". Psychotherapy and Psychosomatics. 90 (3): 160–177. doi: 10.1159/000511348 . PMID   33166960. S2CID   226296398.
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  5. ↑ Roca et al. (2014). Frequency and predictors of psychotic symptoms in a general population sample. Acta Psychiatrica Scandinavica, 129(4), 286-295
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  8. ↑ "ICD-10 Version:2019".
  9. ↑ https://cdn.website-editor.net/30f11123991548a0af708722d458e476/files/uploaded/DSM%2520V.pdf [ bare URL PDF ]
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  46. ↑ Birkenhäger, TK; Pluijms, EM; Lucius, SA (2003). "ECT response in delusional versus non-delusional depressed inpatients". Journal of Affective Disorders. 74 (2): 191–5. doi:10.1016/S0165-0327(02)00005-8. PMID   12706521.
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