Depressive disorders with psychotic features

Major Depressive Disorder with Psychotic Features. One severe subtype of depression is characterized by both depressive and psychotic symptoms. Unless a longitudinal history is available, it can be difficult to distinguish a patient with a psychotic depression from a depressed patient who has a comorbid Cluster A personality disorder. Some qualitative features may be helpful, but these are not wholly reliable. The most prominent psychotic symptoms of a psychotic depression tend to be delusions and auditory hallucinations, but these sometimes present in an attenuated form more reminiscent of Cluster A symptoms. 

Schizoaffective and mood disorder exclusion Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. 

McElroy and her coworkers (109) surveyed the response of 85 consecutive patients, including 14 bipolar patients with psychotic features, who received clozapine for 6 weeks. The response rates of the schizoaffective patients (both bipolar and depressed subtypes), as well as those with bipolar disorders with psychotic features, were excellent (i.e., almost 90%) and substantially better than the response rate for the pure schizophrenic group (i.e., 46%). 

In eight patients with major depressive disorder without psychotic features, who did not respond to serotonin re-uptake inhibitors therapy when risperidone was added, all improved within 1 week. Furthermore, risperidone also seemed to have beneficial effects on sleep disturbance and sexual dysfunction (47). In an open study in 30 healthy subjects who took risperidone 1 mg orally... 

A 38-year-old man with major depressive disorder and psychotic features developed rabbit syndrome after taking risperidone 4 mg/day and paroxetine 40 mg/ day for 4 months he was also taking simvastatin 10 mg/day, thiamine 100 mg/day, and folic acid 1 mg/ day (104). 

In eight patients with major depressive disorder without psychotic features, who did not respond to serotonin reuptake inhibitors therapy when risperidone was added, all improved within 1 week. Furthermore, risperidone also seemed to have beneficial effects on sleep disturbance and sexual dysfunction (272). In an open study in 30 healthy subjects who took risperidone 1 mg orally before and after venlafaxine dosing to steady state, the oral clearance of risperidone fell by 38% and the volume of distribution by 17%, resulting in a 32% increase in AUC renal clearance of 9-hydroxyrisperidone also fell by 20% (273). The authors concluded that these small effects were consistent with the fact that venlafaxine is unlikely to alter the clearance of risperidone, which is mainly by CYP2D6. 

Schizophrenia and Schizoaffective Disorder. Cross sectionally, it is often difficult to distinguish major depression with psychotic features from the schizophrenia spectrum disorders. There are theoretically qualitative differences in the psychosis that may help to make the distinction. Psychosis in the context of a mood disorder tends to be manifested by persecutory and nihilistic themes, but schizophrenia is more often characterized by paranoia and disorganization. However,... 

One of the more methodologically rigorous studies on the utility of TCA/antipsychotic combinations in treating PMD was completed by Spiker et al. [1985). In this study, 54 patients who met criteria for depression with psychotic features on the Schedule for Affective Disorders and Schizophrenia [Endicott and Spitzer 1978) and by Research Diagnostic Criteria [Spitzer et al. 1985) were randomly selected to treatment with amitriptyline alone, perphenazine alone, or the combination of two drugs. After a 7-day placebo washout, patients were treated for 35 days with doses averaging approximately 50 mg/day of perphenazine and approximately 200 mg/day of ami-... 

Mania, depression, and cognitive disorders like Alzheimer s disease may or may not be associated with psychotic features. True or False. 

Several subtypes of depression require specific treatment strategies that go beyond a simple course of conventional antidepressant therapy (these subtypes include bipolar depression, major depression with psychotic features, seasonal depression, atypical depression, comorbid anxiety disorder, comorbid substance abuse, double depression [major depression... 

Use in combination with lithium or valproate for the acute treatment of mania or mixed states (primarily with psychotic features) for bipolar I disorder. Only olanzapine is FDA approved at this time for maintenance treatment and only quetiapine for bipolar depression. 

It is indicated in the treatment of depressive episodes associated with bipolar disorder. A combination of an antipsychotic drug and an antidepressant may be useful in some cases, especially in depressed psychotic patients, or in cases of agitated major depression with psychotic features. The first combination antipsychotic/antidepressant (olanza-pine/fluoxetine Symbyax) was recently FDA approved in the United States for treatment of depressive episodes associated with bipolar disorder. However, antidepressants and stimulants are unlikely to reduce apathy and withdrawal in schizophrenia, and they may induce clinical worsening in some cases. Adjunctive addition of lithium or an antimanic anticonvulsant, such as carbamazepine, may add benefit in some psychotic patients with prominent affective, aggressive, or resistant symptoms. 

In all of these trials, the Hamilton Rating Scale for Depression (HAMD) [260], a well-validated and widely accepted observer rating scale for the assessment of the severity of depressive disorders, was employed as the primary outcome variable (if specified) or as the first of several outcome variables (if no distinction between primary and concomitant variables was made). As patients with psychotic features were excluded from most of the trials, the 17-item version was predominantly used. 

The psychotic disorders include schizophrenia, the manic phase of bipolar (manic-depressive) illness, acute idiopathic psychotic illnesses, and other conditions marked by severe agitation. All exhibit major disturbances in reasoning, often with delusions and hallucinations. Several classes of drugs are effective for symptomatic treatment. Antipsychotic agents also are useful alternatives to electroconvulsive therapy (ECT) in severe depression with psychotic features, and sometimes are used in the management of patients with psychotic disorders associated with delirium or dementia or induced by other agents (e.g., stimulants or L-DOPA). 

Electroconvulsive therapy (ECT) is probably the most effective treatment for major depressive disorder (MDD) with psychotic features, with average response rates of 70-90%, compared with only about 40% for regular antidepressant medications. The response rates for MDD without psychosis are comparable between regular medications and ECT (about 70-75%). ECT is usually given to patients whose condition is refractory to or who are intolerant of antidepressant medication. 

Major depressive disorder (MDD) with psychotic features... 

ECT is the most effective treatment for more severe depressive disorders, often characterized by melancholic and/or psychotic features. Although primarily used for an acute episode, ECT may also be a useful maintenance strategy for patients with frequent relapses despite adequate pharmacotherapy. 

Blumenthal et al. (15) reported that psychotic features in both unipolar and bipolar disorders were indicative of an earlier age of onset and first hospitalization in comparison with their nonpsychotic counterparts. Age of onset for the first episode was found to be earlier in the bipolar group regardless of psychotic categorization. Furthermore, the authors hypothesize that delusional depressions may be related to bipolar disorder, given a higher prevalence of the latter in relatives, and postulate a predictive relationship between psychoticism and bipolarity. 

Bipolar affective (manic-depressive) disorder occurs in 1-3% of the adult population. It may begin in childhood, but most cases are first diagnosed in the third and fourth decades of life. The key symptoms of bipolar disorder in the manic phase are excitement, hyperactivity, impulsivity, disinhibition, aggression, diminished need for sleep, psychotic symptoms in some (but not all) patients, and cognitive impairment. Depression in bipolar patients is phenomenologically similar to that of major depression, with the key features being depressed mood, diurnal variation, sleep disturbance, anxiety, and sometimes, psychotic symptoms. Mixed manic and depressive symptoms are also seen. Patients with bipolar disorder are at high risk for suicide. 

Depressive and anxious symptoms are frequently associated with schizophrenia, but this does not necessarily mean that they fulfill the diagnostic criteria for a comorbid anxiety or affective disorder. Nevertheless, depressed mood, anxious mood, guilt, tension, irritability, and worry frequently accompany schizophrenia. These various symptoms are also prominent features of major depressive disorder, psychotic depression, bipolar disorder, schizoaffective disorder, organic dementias, and childhood... 

Inquire about the preceding symptoms from the caregivers, and address any concerns they may have with specific attention to sleep disorders, depression, psychotic features, and dyskinesias that may not be apparent to the patient. 

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