Depression in schizophrenia
- Samuel G Siris, MD
Samuel G Siris, MD
- Professor Emeritus
- Hofstra North Shore LIJ School of Medicine
- Raphael J Braga, MD
Raphael J Braga, MD
- Center for Treatment and Research of Bipolar Disorder
- The Zucker Hillside Hospital
Depressive symptoms are frequent clinical features in patients with schizophrenia. Depression is associated with a less favorable patient course and outcomes compared to patients with schizophrenia without depression.
The diagnosis of depression in schizophrenia is complicated by a differential diagnosis that includes depression-like extrapyramidal symptoms of antipsychotic drugs, negative symptoms of schizophrenia, and organic conditions. In addition to thorough assessment, treatment trials can be used to differentiate these conditions.
The epidemiology, clinical manifestations, diagnosis, and treatment of depression in patients with schizophrenia are discussed here. Depression and schizophrenia as individual, non-comorbid disorders are discussed separately. Other common comorbidities of schizophrenia are also discussed separately. (See "Schizophrenia: Clinical manifestations, course, assessment, and diagnosis" and "Pharmacotherapy for schizophrenia: Acute and maintenance phase treatment" and "Unipolar depression in adults: Epidemiology, pathogenesis, and neurobiology" and "Unipolar depression in adults: Assessment and diagnosis" and "Unipolar major depression in adults: Choosing initial treatment" and "Co-occurring schizophrenia and substance use disorder: Epidemiology, pathogenesis, clinical manifestations, and diagnosis" and "Anxiety in schizophrenia" and "Unipolar depression in adults: Course of illness".)
Estimates of the lifetime prevalence of depression in schizophrenia vary widely — from 6 to 75 percent — based on differing study characteristics including varying definitions of depression, patient settings, and durations of observation [1-4]. Overall, studies have found a modal prevalence of approximately 25 percent, well above the rate of depression in the general population. (See "Unipolar depression in adults: Epidemiology, pathogenesis, and neurobiology".)
Risk factors for depression in schizophrenia include family history of depressive disorder , high levels of family and personal expectations for success in life, critical family attitudes, high levels of family expressed emotion, stigma, intelligence and insight, multiple hospitalizations, recent hospital discharge, and lack or loss of psychosocial support or support of self-esteem.
- Siris, SG, .Bench, C. Depression and schizophrenia. In: Schizophrenia, Schizophrenia, Hirsch, S.R. and Weinberg, D.R. (Eds), Blackwell Publishing Company, Malden 2003. p.142.
- Conus P, Abdel-Baki A, Harrigan S, et al. Pre-morbid and outcome correlates of first episode mania with psychosis: is a distinction between schizoaffective and bipolar I disorder valid in the early phase of psychotic disorders? J Affect Disord 2010; 126:88.
- Buckley PF, Miller BJ, Lehrer DS, Castle DJ. Psychiatric comorbidities and schizophrenia. Schizophr Bull 2009; 35:383.
- Hausmann A, Fleischhacker WW. Differential diagnosis of depressed mood in patients with schizophrenia: a diagnostic algorithm based on a review. Acta Psychiatr Scand 2002; 106:83.
- Subotnik KL, Nuechterlein KH, Asarnow RF, et al. Depressive symptoms in the early course of schizophrenia: relationship to familial psychiatric illness. Am J Psychiatry 1997; 154:1551.
- Siris SG. Depression in schizophrenia: perspective in the era of "Atypical" antipsychotic agents. Am J Psychiatry 2000; 157:1379.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th, text revision, American Psychiatric Association, Washington, DC 2000.
- Conley RR, Ascher-Svanum H, Zhu B, et al. The burden of depressive symptoms in the long-term treatment of patients with schizophrenia. Schizophr Res 2007; 90:186.
- Siris SG. Suicide and schizophrenia. J Psychopharmacol 2001; 15:127.
- Palmer BA, Pankratz VS, Bostwick JM. The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry 2005; 62:247.
- Hawton K, Sutton L, Haw C, et al. Schizophrenia and suicide: systematic review of risk factors. Br J Psychiatry 2005; 187:9.
- Dalack GW, Healy DJ, Meador-Woodruff JH. Nicotine dependence in schizophrenia: clinical phenomena and laboratory findings. Am J Psychiatry 1998; 155:1490.
- Griffiths, RR, .Mumford, GK. Caffeine: a drug of abuse. In: Psychopharmacology: the Fourth Generation of Progress, Bloom, F.E. and Kupfer, D.J. (Eds), Raven Press, New York 1995. p.1699.
- Awad AG. Subjective response to neuroleptics in schizophrenia. Schizophr Bull 1993; 19:609.
- Harrow M, Yonan CA, Sands JR, Marengo J. Depression in schizophrenia: are neuroleptics, akinesia, or anhedonia involved? Schizophr Bull 1994; 20:327.
- Wise, RA. Neuroleptics and operant behavior: the anhedonia hypothesis. Behav Brain Sci 1982; 5:39.
- Rifkin, A, Quitkin, F, Klein, DF. Akinesia: A Poorly Recognized Drug-Induced Extrapyramidal Behavioral Disorder. Arch Gen Psychiatry 1975; 32:672.
- Van Putten T, May RP. "Akinetic depression" in schizophrenia. Arch Gen Psychiatry 1978; 35:1101.
- Van, Putten, T. The many faces of akathisia. Comp Psychiatry 1975; 16:43.
- Siris SG. Three cases of akathisia and "acting out". J Clin Psychiatry 1985; 46:395.
- Hansen, L. A critical review of akathisia, and its possible association with suicidal behavior. Human Psychopharmacology: Clinical and Experimental 2001; 16:495.
- Bermanzohn PC, Siris SG. Akinesia: a syndrome common to parkinsonism, retarded depression, and negative symptoms of schizophrenia. Compr Psychiatry 1992; 33:221.
- Carpenter WT Jr, Heinrichs DW, Alphs LD. Treatment of negative symptoms. Schizophr Bull 1985; 11:440.
- Andreasen NC, Olsen S. Negative v positive schizophrenia. Definition and validation. Arch Gen Psychiatry 1982; 39:789.
- Herz MI, Melville C. Relapse in schizophrenia. Am J Psychiatry 1980; 137:801.
- Rosen JL, Miller TJ, D'Andrea JT, et al. Comorbid diagnoses in patients meeting criteria for the schizophrenia prodrome. Schizophr Res 2006; 85:124.
- Koreen AR, Siris SG, Chakos M, et al. Depression in first-episode schizophrenia. Am J Psychiatry 1993; 150:1643.
- Clarke DM, Kissane DW. Demoralization: its phenomenology and importance. Aust N Z J Psychiatry 2002; 36:733.
- Frank, JD. Persuasion and Healing, Johns Hopkins University Press, Baltimore, MD p.1973.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
- Emsley RA, Buckley P, Jones AM, Greenwood MR. Differential effect of quetiapine on depressive symptoms in patients with partially responsive schizophrenia. J Psychopharmacol 2003; 17:210.
- Marder SR, Davis JM, Chouinard G. The effects of risperidone on the five dimensions of schizophrenia derived by factor analysis: combined results of the North American trials. J Clin Psychiatry 1997; 58:538.
- Tollefson GD, Sanger TM, Lu Y, Thieme ME. Depressive signs and symptoms in schizophrenia: a prospective blinded trial of olanzapine and haloperidol. Arch Gen Psychiatry 1998; 55:250.
- Mauri MC, Moliterno D, Rossattini M, Colasanti A. Depression in schizophrenia: comparison of first- and second-generation antipsychotic drugs. Schizophr Res 2008; 99:7.
- Turkington D, Kingdon D. Cognitive-behavioural techniques for general psychiatrists in the management of patients with psychoses. Br J Psychiatry 2000; 177:101.
- Bustillo J, Lauriello J, Horan W, Keith S. The psychosocial treatment of schizophrenia: an update. Am J Psychiatry 2001; 158:163.
- Whitehead, C, Moss, S, Cardno, A, et al. Antidepressants for people with both schizophrenia and depression. Cochrane Database of Systematic Reviews 2002; :CD002305.
- Siris SG, Morgan V, Fagerstrom R, et al. Adjunctive imipramine in the treatment of postpsychotic depression. A controlled trial. Arch Gen Psychiatry 1987; 44:533.
- Kramer MS, Vogel WH, DiJohnson C, et al. Antidepressants in 'depressed' schizophrenic inpatients. A controlled trial. Arch Gen Psychiatry 1989; 46:922.
- Centorrino F, Baldessarini RJ, Frankenburg FR, et al. Serum levels of clozapine and norclozapine in patients treated with selective serotonin reuptake inhibitors. Am J Psychiatry 1996; 153:820.
- Siris SG, van Kammen DP, Docherty JP. Use of antidepressant drugs in schizophrenia. Arch Gen Psychiatry 1978; 35:1368.
- Siris SG, Bermanzohn PC, Mason SE, Shuwall MA. Maintenance imipramine therapy for secondary depression in schizophrenia. A controlled trial. Arch Gen Psychiatry 1994; 51:109.
- Addington D, Addington J, Maticka-Tyndale E, Joyce J. Reliability and validity of a depression rating scale for schizophrenics. Schizophr Res 1992; 6:201.
- CLINICAL MANIFESTATIONS
- DIFFERENTIAL DIAGNOSIS
- Organic factors
- Antipsychotic drug-induced dysphoria
- Extrapyramidal side effects of antipsychotics
- Negative symptoms of schizophrenia
- Prodrome of a psychotic episode
- Disappointment reactions
- Depression in schizophrenia
- - Schizoaffective disorder
- ASSESSMENT AND MANAGEMENT
- Antipsychotic medication effects
- Pharmacotherapy for depressive disorders
- - Major depression
- - Other depressive disorders
- SUMMARY AND RECOMMENDATIONS