* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download When clinical psychosis accompanies depression
David J. Impastato wikipedia , lookup
Spectrum disorder wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
History of electroconvulsive therapy in the United Kingdom wikipedia , lookup
History of mental disorders wikipedia , lookup
Abnormal psychology wikipedia , lookup
Child psychopathology wikipedia , lookup
Emergency psychiatry wikipedia , lookup
Schizoaffective disorder wikipedia , lookup
Bipolar II disorder wikipedia , lookup
Antipsychotic wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Postpartum depression wikipedia , lookup
Mental status examination wikipedia , lookup
Major depressive disorder wikipedia , lookup
Biology of depression wikipedia , lookup
Behavioral theories of depression wikipedia , lookup
Forum Mental Health depression/SM/SS/NH2.qxd 28/04/2008 14:33 Page 1 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 FORUM May 2008 55 depression/SM/SS/NH2.qxd 28/04/2008 Forum 14:34 Page 2 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