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28/04/2008
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When clinical psychosis
accompanies depression
Depression combined with psychosis is an extremely debilitating
condition that requires prompt diagnosis, writes Jennifer Grant
CLINICAL DEPRESSION is a broad concept. For the purpose of
defining a diagnosable and treatable clinical entity, it is a
condition characterised by pathologically low mood. It
embodies a broad spectrum of conditions, with unhappiness
at one end of the spectrum and severe ‘endogenous’ biological type mood disorders at the other end. An external
precipitating cause is often not required and especially so
in states of severe depression. From a purely medical point
of view, depression is an illness characterised by a series of
depressive symptoms with prescribed treatments. There are
other ways of defining it however, according to sociological,
existential and psychological standpoints.
Clinical or major depressive disorder is characterised by
either a depressed mood or loss of interest or pleasure in
most activities, lasting for a period of at least two weeks.
This has to represent a deterioration from previous functioning, causing the person clinically significant distress.
Major depressive episodes are further classified as mild,
moderate or severe and with or without psychotic features
and melancholia.
There is clearly a great imperative to treat major depression,
because of the adverse impact on the person, but especially
to avoid progression to a state of severe or profound depression accompanied by psychotic symptoms. Some authors
perceive psychotic (unipolar) depression to be a distinct subtype of depression however, and not just a progression to a
severe form as it may present in this way at the outset with a
relatively short antecedent period of illness.
Psychotic (unipolar) depression
It is estimated 10%-15% of patients with depression have
associated psychotic symptoms, often mood-congruent delusions and hallucinations.1 Psychosis is defined as a loss of
contact with reality, often exhibited by hallucinations, delusional beliefs, disorganised thinking or bizarre behaviour.
Mood disorders can be accompanied by psychosis, including Schneiderian first-rank symptoms.
In typical cases of psychotic depression, the depressed
mood is episodic and psychotic symptoms are only present
during the depressive episodes, and not in the intervening
time. When more persistent psychotic features are present,
there needs to be awareness that this may be a manifestation of a schizoaffective disorder, where there are not only
depressive symptoms but also those of schizophrenia. It is
important to consider psychotic depression in cases of treatment-refractory depression. Psychosis can be subtle, eg.
somatic preoccupation or self-reproach, and in some
patients paranoia is so prominent that the depressive
episode is missed entirely.2
Table 1
Differential diagnosis of
psychosis with depression2
• Psychotic unipolar depression
• Psychotic bipolar depression
• Schizophrenia-spectrum disorders
• Post-psychotic depression
• Delusional disorder with depressive overlay
• Dementia with psychosis
• Organic syndromes with psychosis and depression
The full syndrome of psychotic depression is unmistakable. Some patients show extreme psychomotor retardation;
others are agitated, ruminating without reprieve about the
mood-congruent delusional themes of guilt, worthlessness
and death. Some patients lament their fate and ask to be
put out of their misery. They perceive themselves to be a
burden to family and society, and suicide can be a constant
thought. Paranoid ideation and ideas or delusions of reference are common.
Family members may feel exasperated at accusations of
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depression/SM/SS/NH2.qxd
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Mental Health
Table 2
3
Recommendations for the treatment of psychotic depression
Therapeutic choice
First choice
Second choice
Recommendations
Evidence
ECT
Level 1
Antipsychotic + antidepressant
(olanzapine or risperidone with SSRI or SNRI)
Level 2
Typical antipsychotic + amitriptyline
Level 2
stealing from the depressed person and the person’s delusions of impoverishment. In the extreme of nihilistic
delusions, patients deny any future or their own existence,
to the point of claiming to be already dead.
Screening questions
When assessing a patient with depression it is often easy
to forget to ask about psychotic symptoms and unless the
relevant questions are asked, the agitated or seemingly restless patient may not volunteer. Delusions of thought
interference can be elicited by asking: “Can you think quite
clearly or are you fully in control of your thoughts and
actions?”
Thought echo, thought insertion, thought withdrawal or
thought broadcast may also be present. If a patient feels
that things have a special meaning for them they may be
experiencing delusions of reference. This may come to
attention on asking a question like: “Has there been any reference to you recently in the newspapers, on the radio or on
the television?”
A very common delusional theme is that of persecutory
delusions and may be screened for by asking a question like:
“Is any one trying to harm you or plot against you?” Similarly delusions of guilt are often associated with psychotic
depression; ask: “Do you feel as if you have committed a
crime or have you harmed some one?”
Particularly in the older patient nihilistic delusions or
hypochondriacal delusions may be present: “Is something
terrible about to happen? Are you suffering from any serious
disease or is any part of your body unhealthy?” Hallucinations may be auditory, visual or tactile and somatic as well
as gustatatory or olfactory: “Have you heard anything
unusual recently? Have you heard people speaking when
there is no-one in the room? Are the voices talking directly
to you (second person auditory hallucinations) or do they
talk about you? (third person auditory hallucinations).”
The older population
Psychotic depression, as already stated, is one of the most
serious types of depression and may occur more commonly
in an older population. Moreover, in this population, symptom presentation is more severe, relapses may be more
frequent, and remission is more likely to be incomplete.
Delusions tend to be mood congruent with themes of inadequacy and worthlessness, impoverishment, exaggerated
guilt, and death and dying.
Somatic delusions involve misperceptions of impaired or
poorly functioning bodily systems. Paranoid, persecutory, or
jealous delusions may also be present. Hallucinations are
uncommon and tend to be transitory but consistent with
depressive themes.
Some patients with delusional depression have significant
cognitive impairment that develops after the onset of mood
symptoms, a condition previously termed pseudodementia.
56 FORUM May 2008
The condition is now referred to as dementia syndrome of
depression, since the cognitive deficits are demonstrable
and real. These patients may be at higher risk of converting
to an irreversible dementia syndrome such as Alzheimer’s
disease which can be revealed by longer-term follow-up.1
Associated factors include subacute onset, a prior history
of depression, a family history of depression, and both
memory and frontal executive dysfunction. Both cognitive
and mood symptoms can respond to antidepressants. This
response distinguishes these patients from those with
depression complicating AD, in whom antidepressant therapy improves depressive symptoms but the primary cognitive
deficits of AD remain and progressively worsen.
Treatment
If acute suicidality or florid psychosis is present, or if the
patient becomes medically compromised (eg. not eating or
drinking), a period of hospitalisation may be warranted with
involuntary admission being necessary on occasion. An antidepressant combined with an antipsychotic is usually the
treatment of choice, followed by ECT if medication fails.
Full doses of antipsychotic drugs such as quetiapine,
amisulpride, risperidone or olanzapine need to be utilised.
Older tricyclic drugs such as amitriptyline or clomipramine
can be used in combination with an antipsychotic, but
SSRIs or SNRIs (venlafaxine or duloxetine) are preferred initially.
In a meta-analysis, ECT was superior to TCA alone, but not
significantly better than the combination of TCA and
antipsychotic therapy.3 It has also been demonstrated that
bilateral ECT is more effective than unilateral ECT. Given
the high relapse rate associated with ECT, the literature supports the use of pharmacotherapy for maintenance
treatment and prophylaxis even when ECT has been successfully applied.3
Prophylactic or maintenance medication will be required
on an ongoing basis for two to five years after an episode of
psychotic depression, and upon achieving remission, the
antipsychotic should be weaned first after that time interval. Lithium prophylaxis has also been successfully applied
in this group of patients.
As with all patients suffering from a major medical illness,
psycho-education, insight enhancement and engagement
with services, often on an extended basis, appears crucial
in keeping these vulnerable patients free from relapsing and
recurrent episodes.
Jennifer Grant is registrar in psychiatry, St Patrick’s Hospital,
Dublin
References
1. Lawler B. Revision psychiatry. Medmedia Ltd, Dublin 2001; 111.
2. Freudenreich O. Psychotic disorders- practical guides in psychiatry.
Wolter Kluwer/Lippincott 2008; Ch 6: 45-49.
3. Kennedy SH, Lam RW, Nutt DJ, Thase ME. Treating depression
effectively – applying clinical guidelines. 2007; Ch 5: 65-66