Psychotic symptoms and vulnerability to recurrent major depression

doi:10.1016/0165-0327(94)00080-S

Journal of Affective Disorders

Volume 33, Issue 2, 21 February 1995, Pages 107-115

https://doi.org/10.1016/0165-0327(94)00080-S Get rights and content

Abstract

The demographic characteristics and psychiatric course of primary unipolar depressed patients, either with or without psychotic features, were compared in a retrospective study. 15% ( $25165$ ) of the patients had had at least one episode of psychotic depression. Compared with the 140 non-psychotic patients, the psychotic patients were more likely to be female, had been ill for significantly longer and endured significantly more episodes of depression. The greater number of episodes was not attributable to the greater length of illness. Various reasons for the group differences are examined. Particular consideration is given to the possibility that a propensity for recurrent psychotic major depression might be related to sensitized dopamine neurons.

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2011, Journal of Affective Disorders
Citation Excerpt :
Our results revealed a number of robust differences in the clinical picture of Psychotic Mood Disorders (PMD), when compared to affective disorders with no history of psychotic symptoms. In line with previous findings, a number of negative prognostic factors were associated with PMD: a higher prevalence of BP-I diagnosis (Goes et al., 2007), a younger age at the first hospitalization (Jager et al., 2005), a higher number of mood episodes lifetime (Leyton et al., 1995; Coryell et al., 1996; Coryell et al., 2001), a younger age at illness onset (Lenzi et al., 1996) and, above all, a higher prevalence of early onset (before the age of 21) of mood symptoms. Other studies had also found a higher number of hospitalizations (Jager et al., 2005) in PMD patients, but in our sample lifetime duration of hospitalization was not different between groups.
The nosological and clinical implications of psychotic features in the course of mood disorders have been widely debated. Currently, no specification exists for defining a subgroup of lifetime Psychotic Mood Disorder (PMD) patients.
A total of 2178 patients were examined, including subjects with Bipolar Disorder (BP) type I (n = 519) and II (n = 207) and Major Depressive Disorder (n = 1452). Patients were divided between PMD (n = 645) and non-psychotic Mood Disorders (MD) (n = 1533) by the lifetime presence of at least one mood episode with psychotic features. Subjects having a depressive episode at the time of assessment were also examined: HAM-D and YMRS scores were compared between MD and PMD subjects, both with and without current psychotic features.
A diagnosis of BP-I, a higher familial load for BP, a higher number of mood episodes lifetime, and a higher prevalence of OCD and somatic comorbidities were all associated to PMD. A diagnosis of BP (OR = 4.48) was the only significant predictor for psychosis. PMD with non-psychotic depression were apparently less severe than MD patients and had a lower rate of “non-responders” to AD treatment. Sub-threshold manic symptoms and suicidal risk were also more pronounced among PMD.
The lack of information about number and polarity of previous psychotic mood episodes may be the major limitations of our study.
BP diagnosis is the most significant predictor for psychosis in mood disorders. Non-psychotic mood episodes in PMD patients may be characterized by a distinctive symptom profile and, possibly, a different response to treatment.
Fifteen-year follow-up of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition depressive disorders: The prognostic significance of psychotic features
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Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), after Kraepelin's original description of “manic-depressive insanity,” embodied a broad concept of affective disorders including mood-congruent and mood-incongruent psychotic features. Controversial results have been reported about the prognostic significance of psychotic symptoms in depressive disorders challenging this broad concept of affective disorders. One hundred seventeen inpatients first hospitalized in 1980 to 1982 who retrospectively fulfilled the DSM-IV criteria for depressive disorders with mood-congruent or mood-incongruent psychotic features (n = 20), nonpsychotic depressive disorders (n = 33), or schizophrenia (n = 64) were followed up 15 years after their first hospitalization. Global functioning was recorded with the Global Assessment Scale; the clinical picture at follow-up was assessed using the Hamilton Rating Scale for Depression, the Positive and Negative Syndrome Scale, and the Scale for the Assessment of Negative Symptoms. With respect to global functioning, clinical picture, and social impairment at follow-up, depressive disorders with psychotic features were similar to those without, but markedly different from schizophrenia. However, patients with psychotic depressive disorders experienced more rehospitalizations than those with nonpsychotic ones. The findings indicating low prognostic significance of psychotic symptoms in depressive disorders are in line with the broad concept of affective disorders in DSM-IV.
Psychosocial impairment and recurrence of major depression
2004, Comprehensive Psychiatry
Major depressive disorder is often marked by multiple recurrences. Unfortunately, it is difficult to predict specifically which patients will suffer a recurrence. This study examined whether psychosocial impairment is a risk factor for recurrence. A total of 290 subjects with unipolar major depressive disorder according to Research Diagnostic Criteria (RDC) were prospectively followed for up to 15 years as part of the Collaborative Depression Study (CDS), a multicenter longitudinal observational study of the mood disorders. Follow-up data on course of illness and psychosocial functioning were collected with the Longitudinal Interval Follow-up Evaluation (LIFE). The association of psychosocial impairment with recurrence of major depression was examined with mixed-effects logistic regression. The mean (SD) score for psychosocial functioning during recovery from an episode of major depression was 9.0 (2.7), with a possible range of 4 (no impairment) to 20 (severe impairment). For euthymic subjects who recovered from an episode of major depression, elevated psychosocial impairment was significantly associated with subsequent recurrence of major depression, with an odds ratio of 1.12 (95% confidence interval [CI], 1.06 to 1.19). The odds ratio of 1.12 indicates that for each 1-point increase in the functional impairment score, the risk of recurrence increases by about 12%. In patients who have recovered from an episode of major depression, the presence of psychosocial impairment may help identify who is at increased risk of recurrence.
Treatment of non-schizophrenic disorders: Focus on atypical antipsychotics
2004, Journal of Psychiatric Research
Antipsychotics are commonly used for conditions other than schizophrenia, yet support for such use in the literature is unclear. This article reviews the literature on the pharmacologic treatment of specific types of non-schizophrenic disorders: those associated with psychotic depression, obsessive-compulsive disorder, body dysmorphic disorder, bipolar disorder, and dementia. It focuses on the evidence for using antipsychotics in these conditions, placing emphasis on atypical antipsychotics. Medline/HealthStar and PsycInfo databases were used to identify published trials and reports of antipsychotics used specifically for non-schizophrenic disorders. Numerous studies were found supporting the use of atypical antipsychotics for non-schizophrenic disorders; however, with the exception of dementia, few randomized, double-blind controlled trials have been published examining the efficacy and safety of these agents in non-schizophrenic disorders. In general, most trials were restricted to short-term use as adjunctive therapy. The literature reviewed was primarily comprised of small open-label trials, thus making it difficult to draw definitive conclusions. Despite the limitations of the trials reviewed, atypical antipsychotics represent a promising treatment modality when considering their improved side effect profile compared to conventional agents. Appropriate dosing and the use of antipsychotics in combination with psychosocial treatments are important treatment considerations. Due to the frequent clinical use of atypical antipsychotics as adjunctive therapy, well-designed trials of these agents in non-schizophrenic disorders are necessary.
The differentiation of DSM-III-R psychotic depression in later life from nonpsychotic depression: Comparisons of brain changes measured by multispectral analysis of magnetic resonance brain images, neuropsychological findings, and clinical features
1999, Biological Psychiatry
Background: Psychotic depression has been proposed as a distinct subtype of major depression. There is considerable evidence for this in younger patients, although the neuroimaging has been rudimentary. Volumetric imaging studies are required of consecutive cohorts of patients with depression.
Methods: Ninety-nine consecutive elderly patients were diagnosed with DSM-III-R major depression. Eighteen were psychotic, and 81 were not. Sixty-six patients were given a neuropsychological test battery, and 44 had a magnetic resonance imaging brain scan. A model integrating clinical, psychological, and neuroimaging findings for the explanation of delusion formation during depression is proposed.
Results: Psychotic depression was characterized by worse physical health, more family history of depression, a poorer response to antidepressant drugs, and more severe lowering of mood; however, the strongest predictors of the presence of delusions were diencephalic atrophy, reticular activating system lesions, brain stem atrophy, and left-sided frontotemporal atrophy. The psychotic patients had poorer performance on tests of frontal lobe function and mental processing speed.
Conclusions: In the elderly, psychotic depression is etiologically, clinically, and neuroradiologically distinct, and has different treatment requirements, from nonpsychotic major depression.
Clinical and demographic features of psychotic and nonpsychotic depression
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The present study evaluated clinical and demographic features of subjects with delusional versus nondelusional major depressive disorder. Two hundred eighty-eight subjects with mood disorder (bipolar disorder, n = 94; major depressive disorder, n = 194) were included in the study. No differences were observed for gender, polarity of mood disorder, age of onset, duration of index episode, number of episodes, number of previous hospital admissions, frequency of illness episodes, and number of suicide attempts. On the other hand, delusional subjects showed a higher rate of cluster A personality disorder and a lower level of education. We also detected a larger number of cluster B personality disorders among nondelusionals. Our data suggest that subjects with delusional mood disorder do not differ substantially from non-delusionals in terms of the clinical and demographic variables considered in this study except for personality disorders.

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Research paperPsychotic symptoms and vulnerability to recurrent major depression

Abstract

J Affect. Disord.

Compr. Psychiatry

Biol. Psychiatry

Behav. Brain Res.

J. Affect. Disord.

Biol. Psychiatry

Pharm. Biochem. Behav.

Lancet

Eur. J. Pharmacol.

The course of affective disorders

Psychopathology

CSF monoamine metabolites in melancholia

Acta Psychiatr. Scand.

Correlation between cerebral spinal fluid amine metabolites and psychomotor activity in affective disorders

J. Neurochem.

CSF monoamine metabolites in depression and schizophrenia

Am. J. Psychiatry

Hallucinations and delusions in 1,715 patients with unipolar and bipolar affective disorders

Psychopathology

CSF 5-HIAA and HVA following probencid in unipolar depressives treated with amitriptyline

Psychopharmacology

Social Origins of Depression: A Study of Psychiatric Disorder in Women

Life events and ‘endogenous’ depression: a puzzle re-examined

Arch. Gen. Psychiatry

Delusional and non-delusional unipolar depression: further evidence for distinct subtypes

Am. J. Psychiatry

Primary unipolar depression and the prognostic importance of delusions

Arch. Gen. Psychiatry

Dopamine in schizophrenia: a review and reconceptualization

Am. J. Psychiatry

Neurobehavioral aspects of affective disorders

Annu. Rev. Psychol.

Research paper
Psychotic symptoms and vulnerability to recurrent major depression