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Psychotic depression

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Psychotic depression
Other namesDepressive psychosis
A drawing that attempts to capture the sadness, loneliness, and detachment from reality, as described by patients with psychotic depression
SpecialtyPsychiatry
SymptomsHallucinations, delusions, low mood
ComplicationsSelf-harm, Suicide
Usual onset20-40 years old
DurationDays to weeks, sometimes longer
Diagnostic methodClinical interview[1]
Differential diagnosisSchizoaffective disorder, schizophrenia, personality disorders, dissociative disorders
TreatmentMedication, cognitive behavioral therapy
MedicationAnti-depressants, anti-psychotics

Psychotic depression, also known as depressive psychosis, is a major depressive episode that is accompanied by psychotic symptoms.[2] It can occur in the context of bipolar disorder or major depressive disorder.[2] Psychotic depression 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.[2] 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.).[3][4][5][6][7] 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.[8]

Signs and symptoms

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People with psychotic depression experience the symptoms of a major depressive episode, along with one or more psychotic symptoms, including delusions and/or hallucinations.[2] 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.[2] Common themes of mood congruent delusions include guilt, persecution, punishment, personal inadequacy, or disease.[9] Half of patients experience more than one kind of delusion.[2] Delusions occur without hallucinations in about one-half to two-thirds of patients with psychotic depression.[2] Hallucinations can be auditory, visual, olfactory (smell), or tactile (touch), and are congruent with delusional material.[2] Affect is sad, not flat. Severe anhedonia, loss of interest, and psychomotor retardation are typically present.[10]

Cause

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Psychotic symptoms tend to develop after an individual has already had several episodes of depression without psychosis.[2] However, once psychotic symptoms have emerged, they tend to reappear with each future depressive episode.[2] The prognosis for psychotic depression is not considered to be as poor as for schizoaffective disorders or primary psychotic disorders.[2] 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.[2][9]

Family members of those who have experienced psychotic depression are at increased risk for both psychotic depression and schizophrenia.[2][needs update]

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. People who received appropriate treatment for psychotic depression went into "remission" and have reported a quality of life similar to that of people without PD.[11]

Pathophysiology

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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).[2] Those with psychotic depression also have higher ventricular-brain ratios than those with non-psychotic depression.[2]

Diagnosis

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Differential diagnosis

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See also: Depression (differential diagnoses)

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.[2] On the other hand, psychotic depression may be confused with schizoaffective disorder.[2] Due to overlapping symptoms, differential diagnosis includes also dissociative disorders.[12]

Treatment

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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.[13][14][15][16]

There is no evidence for or against the use of mifepristone.[17]

Combined antidepressant and antipsychotic medications

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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.[17] In the context of psychotic depression, the following are the most well-studied antidepressant/antipsychotic combinations:

First-generation

Second-generation

Antidepressant medications

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There is insufficient evidence to determine if treatment with an antidepressant alone is effective.[17] Tricyclic antidepressants may be particularly dangerous, because overdosing has the potential to cause fatal cardiac arrhythmias.[14]

Antipsychotic medications

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There is insufficient evidence to determine if treatment with antipsychotic medications alone is effective.[17] Olanzapine may be an effective monotherapy in psychotic depression,[23] although there is evidence that it is ineffective for depressive symptoms as a monotherapy;[14][21] and olanzapine/fluoxetine is more effective.[14][21] 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.[24][25][26] The current drug-based treatments of psychotic depression are reasonably effective but can cause side effects, such as nausea, headaches, dizziness, and weight gain.[27]

Electroconvulsive therapy

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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.[28] ECT carries the risk of temporary cognitive deficits (e.g., confusion, memory problems), in addition to the burden of repeated exposures to general anesthesia.[29]

Research

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Efforts are made to find a treatment which targets the proposed specific underlying pathophysiology of psychotic depression. A promising candidate was mifepristone,[30] 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.[31]

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:[32] potential precipitating factors,[33][34][35] underlying biology,[36][37][38][39] symptomatology beyond psychotic symptoms,[40][41] long-term prognosis,[42][43] and responsiveness to psychopharmacological treatment and ECT.[44]

Prognosis

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The long-term outcome for psychotic depression is generally poorer than for non-psychotic depression.[14]

References

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  1. ^ 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.
  2. ^ a b c d e f g h i j k l m n o p q Hales E and Yudofsky JA, eds, The American Psychiatric Press Textbook of Psychiatry, Washington, DC: American Psychiatric Publishing, Inc., 2003
  3. ^ Kupfer, D. J., Frank, E., & Phillips, M. L. (2012). Major depressive disorder: New clinical, neurobiological, and treatment perspectives. Lancet, 379(9820), 1045-1055
  4. ^ Roca et al. (2014). Frequency and predictors of psychotic symptoms in a general population sample. Acta Psychiatrica Scandinavica, 129(4), 286-295
  5. ^ García-Álvarez et al. (2013). Residual psychotic symptoms in depression: Prevalence and relationship to mood symptoms, anxiety symptoms, and treatment response. Acta Psychiatrica Scandinavica, 128(5), 375-382
  6. ^ Lennox et al. (2010). Residual psychotic and depressive symptoms in a clinical trial for psychotic depression. Journal of Affective Disorders, 127(1-3), 243-248
  7. ^ "ICD-10 Version:2019".
  8. ^ American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington DC: American Psychiatric Association. ISBN 9780890425558.
  9. ^ a b Practice Guideline for the Treatment of Patients with Major Depressive Disorder (PDF) (3rd ed.). American Psychiatric Association. 2010. doi:10.1176/appi.books.9780890423387.654001. ISBN 978-0-89042-338-7. Retrieved April 6, 2013. {{cite book}}: |work= ignored (help)
  10. ^ Rothschild, A.J., 2009. Clinical Manual for Diagnosis and Treatment of Psychotic Depression. American Psychiatric Publishing, Inc. Washington DC, USA ISBN 978-1-58562-292-4
  11. ^ Bingham, Kathleen (2019). "Health-related quality of life in remitted psychotic depression". Journal of Affective Disorders. 256: 373–379. doi:10.1016/j.jad.2019.05.068. PMC 6822164. PMID 31207561.
  12. ^ Shibayama M (2011). "Differential diagnosis between dissociative disorders and schizophrenia". Psychiatria et Neurologia Japonica. 113 (9): 906–911. PMID 22117396.
  13. ^ "Somatic Treatment of an Acute Episode of Unipolar Psychotic Depression". WebMD LLC. 2013. Retrieved 4 October 2013.
  14. ^ a b c d e Taylor, David; Patron, Carol; Kapur, Shitij (2012). Maudsley Prescribing Guidelines in Psychiatry (11th ed.). West Sussex: John Wiley & Sons, Inc. pp. 233–234. ISBN 9780470979693.
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  28. ^ Bolwig, T. (2011). "How does electroconvulsive therapy work? Theories on its mechanism". The Canadian Journal of Psychiatry. 56 (1): 13–18. doi:10.1177/070674371105600104. PMID 21324238.
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  31. ^ Mifepristone#cite ref-20
  32. ^ Ostergaard, SD; Rothschild, AJ; Uggerby, P; Munk-Jørgensen, P; Bech, P; Mors, O (2012). "Considerations on the ICD-11 classification of psychotic depression". Psychotherapy and Psychosomatics. 81 (3): 135–44. doi:10.1159/000334487. PMID 22398817.
  33. ^ Østergaard, Søren Dinesen; Petrides, Georgios; Dinesen, Peter Thisted; Skadhede, Søren; Bech, Per; Munk-Jørgensen, Povl; Nielsen, Jimmi (2013). "The Association between Physical Morbidity and Subtypes of Severe Depression". Psychotherapy and Psychosomatics. 82 (1): 45–52. doi:10.1159/000337746. PMID 23147239. S2CID 29557858.
  34. ^ Østergaard, Søren Dinesen; Waltoft, Berit Lindum; Mortensen, Preben Bo; Mors, Ole (2013). "Environmental and familial risk factors for psychotic and non-psychotic severe depression". Journal of Affective Disorders. 147 (1–3): 232–40. doi:10.1016/j.jad.2012.11.009. PMID 23228568.
  35. ^ Domschke, Katharina; Lawford, Bruce; Young, Ross; Voisey, Joanne; Morris, C. Phillip; Roehrs, Tilmann; Hohoff, Christa; Birosova, Eva; Arolt, Volker; Baune, Bernhard T. (2011). "Dysbindin (DTNBP1) – A role in psychotic depression?". Journal of Psychiatric Research. 45 (5): 588–95. doi:10.1016/j.jpsychires.2010.09.014. PMID 20951386.
  36. ^ Nelson, JC; Davis, JM (1997). "DST studies in psychotic depression: A meta-analysis". The American Journal of Psychiatry. 154 (11): 1497–503. doi:10.1176/ajp.154.11.1497. PMID 9356556.
  37. ^ Posener, JA; Debattista, C; Williams, GH; Chmura Kraemer, H; Kalehzan, BM; Schatzberg, AF (2000). "24-Hour monitoring of cortisol and corticotropin secretion in psychotic and nonpsychotic major depression". Archives of General Psychiatry. 57 (8): 755–60. doi:10.1001/archpsyc.57.8.755. PMID 10920463.
  38. ^ Cubells, JF; Price, LH; Meyers, BS; Anderson, GM; Zabetian, CP; Alexopoulos, GS; Nelson, JC; Sanacora, G; Kirwin, P; Carpenter, L; Malison, RT; Gelernter, J (2002). "Genotype-controlled analysis of plasma dopamine beta-hydroxylase activity in psychotic unipolar major depression". Biological Psychiatry. 51 (5): 358–64. doi:10.1016/S0006-3223(01)01349-X. PMID 11904129. S2CID 23371102.
  39. ^ Meyers, BS; Alexopoulos, GS; Kakuma, T; Tirumalasetti, F; Gabriele, M; Alpert, S; Bowden, C; Meltzer, HY (1999). "Decreased dopamine beta-hydroxylase activity in unipolar geriatric delusional depression". Biological Psychiatry. 45 (4): 448–52. doi:10.1016/S0006-3223(98)00085-7. PMID 10071716. S2CID 19469775.
  40. ^ Maj, M; Pirozzi, R; Magliano, L; Fiorillo, A; Bartoli, L (2007). "Phenomenology and prognostic significance of delusions in major depressive disorder: A 10-year prospective follow-up study". The Journal of Clinical Psychiatry. 68 (9): 1411–7. doi:10.4088/JCP.v68n0913. PMID 17915981.
  41. ^ Østergaard, SD; Bille, J; Søltoft-Jensen, H; Lauge, N; Bech, P (2012). "The validity of the severity-psychosis hypothesis in depression". Journal of Affective Disorders. 140 (1): 48–56. doi:10.1016/j.jad.2012.01.039. PMID 22381953.
  42. ^ Coryell, W; Leon, A; Winokur, G; Endicott, J; Keller, M; Akiskal, H; Solomon, D (1996). "Importance of psychotic features to long-term course in major depressive disorder". The American Journal of Psychiatry. 153 (4): 483–9. doi:10.1176/ajp.153.4.483. PMID 8599395.
  43. ^ Ostergaard, SD; Bertelsen, A; Nielsen, J; Mors, O; Petrides, G (2013). "The association between psychotic mania, psychotic depression and mixed affective episodes among 14,529 patients with bipolar disorder" (PDF). Journal of Affective Disorders. 147 (1–3): 44–50. doi:10.1016/j.jad.2012.10.005. PMID 23122529.
  44. ^ 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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