Unipolar major depression with psychotic features: Acute treatment
- Anthony J Rothschild, MD
Anthony J Rothschild, MD
- Irving S. and Betty Brudnick Endowed Chair and Professor of Psychiatry
- University of Massachusetts Medical School
Unipolar major depression with psychotic features is a severe subtype of unipolar major depression (major depressive disorder) . The psychotic symptoms are delusions and/or hallucinations that are frequently consistent with depressive themes of guilt and worthlessness . Psychotic depression and nonpsychotic depression differ in their diagnosis, treatment, and prognosis.
This topic reviews the acute treatment of unipolar major depression with psychotic features. Maintenance treatment and prognosis are discussed elsewhere, as are the epidemiology, pathogenesis, clinical features, assessment, and diagnosis of psychotic depression. (See "Unipolar major depression with psychotic features: Maintenance treatment and course of illness" and "Unipolar major depression with psychotic features: Epidemiology, clinical features, assessment, and diagnosis".)
Unipolar major depression with psychotic features is characterized by an episode of unipolar major depression that includes delusions and/or hallucinations .
Unipolar major depression (major depressive disorder) is diagnosed in patients who have suffered at least one major depressive episode (table 1) and have no history of mania (table 2) or hypomania (table 3) . A major depressive episode is a two week or longer period with five or more of the following symptoms: depressed mood, loss of interest or pleasure in most activities, insomnia or hypersomnia, change in appetite or weight, psychomotor retardation or agitation, low energy, poor concentration, guilt, and recurrent thoughts about death or suicide. The clinical presentation and diagnosis of unipolar major depression are discussed further elsewhere. (See "Unipolar depression in adults: Assessment and diagnosis".)
The primary distinction between unipolar major depression with psychotic features and unipolar major depression without psychotic features is that psychotic depression includes :To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Johnson J, Horwath E, Weissman MM. The validity of major depression with psychotic features based on a community study. Arch Gen Psychiatry 1991; 48:1075.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- Marcus SC, Olfson M. National trends in the treatment for depression from 1998 to 2007. Arch Gen Psychiatry 2010; 67:1265.
- Depression: TheTreatment and Management of Depression in Adults (Updated Edition). National Clinical Practice Guideline 90. National Institute for Health & Clinical Excellence. http://guidance.nice.org.uk/CG90 (Accessed on July 18, 2011).
- Østergaard SD, Meyers BS, Flint AJ, et al. Measuring psychotic depression. Acta Psychiatr Scand 2014; 129:211.
- Østergaard SD, Meyers BS, Flint AJ, et al. Measuring treatment response in psychotic depression: the Psychotic Depression Assessment Scale (PDAS) takes both depressive and psychotic symptoms into account. J Affect Disord 2014; 160:68.
- Østergaard SD, Pedersen CH, Uggerby P, et al. Clinical and psychometric validation of the psychotic depression assessment scale. J Affect Disord 2015; 173:261.
- Østergaard SD, Rothschild AJ, Flint AJ, et al. Rating scales measuring the severity of psychotic depression. Acta Psychiatr Scand 2015; 132:335.
- Østergaard SD, Rothschild AJ, Flint AJ, et al. Establishing the cut-off score for remission and severity-ranges on the Psychotic Depression Assessment Scale (PDAS). J Affect Disord 2016; 190:111.
- HAMILTON M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23:56.
- Rhoades HM, Overall JE. The semistructured BPRS interview and rating guide. Psychopharmacol Bull 1988; 24:101.
- American Psychiatric Association. Practice guideline for the treatment of major depressive disorder, third edition. Am J Psychiatry 2010; 167:10 (supplement).
- American Psychiatric Association: Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition. http://www.psych.org/MainMenu/PsychiatricPractice/PracticeGuidelines_1.aspx (Accessed on July 18, 2011).
- Kroessler D. Relative Efficacy Rates for Therapies of Delusional Depression. Convuls Ther 1985; 1:173.
- Rothschild AJ. Clinical Manual for Diagnosis and Treatment of Psychotic Depression, American Psychiatric Publishing, Inc., Washington, DC 2009.
- Olfson M, Marcus S, Sackeim HA, et al. Use of ECT for the inpatient treatment of recurrent major depression. Am J Psychiatry 1998; 155:22.
- Stoskopf C, Horn SD. Predicting length of stay for patients with psychoses. Health Serv Res 1992; 26:743.
- Wilson KG, Kraitberg NJ, Brown JH, Bergman JN. Electroconvulsive therapy in the treatment of depression: the impact on length of stay. Compr Psychiatry 1991; 32:345.
- Parker G, Roy K, Hadzi-Pavlovic D, Pedic F. Psychotic (delusional) depression: a meta-analysis of physical treatments. J Affect Disord 1992; 24:17.
- Rothschild AJ. Management of psychotic, treatment-resistant depression. Psychiatr Clin North Am 1996; 19:237.
- Meyers BS, Flint AJ, Rothschild AJ, et al. A double-blind randomized controlled trial of olanzapine plus sertraline vs olanzapine plus placebo for psychotic depression: the study of pharmacotherapy of psychotic depression (STOP-PD). Arch Gen Psychiatry 2009; 66:838.
- Rothschild AJ, Williamson DJ, Tohen MF, et al. A double-blind, randomized study of olanzapine and olanzapine/fluoxetine combination for major depression with psychotic features. J Clin Psychopharmacol 2004; 24:365.
- Wijkstra J, Burger H, van den Broek WW, et al. Treatment of unipolar psychotic depression: a randomized, double-blind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine. Acta Psychiatr Scand 2010; 121:190.
- Müller-Siecheneder F, Müller MJ, Hillert A, et al. Risperidone versus haloperidol and amitriptyline in the treatment of patients with a combined psychotic and depressive syndrome. J Clin Psychopharmacol 1998; 18:111.
- Spiker DG, Weiss JC, Dealy RS, et al. The pharmacological treatment of delusional depression. Am J Psychiatry 1985; 142:430.
- Kim-Romo DN, Rascati KL, Richards KM, et al. Medication Adherence and Persistence in Patients with Severe Major Depressive Disorder with Psychotic Features: Antidepressant and Second-Generation Antipsychotic Therapy Versus Antidepressant Monotherapy. J Manag Care Spec Pharm 2016; 22:588.
- Lam RW, Kennedy SH, Grigoriadis S, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy. J Affect Disord 2009; 117 Suppl 1:S26.
- Leadholm AK, Rothschild AJ, Nolen WA, et al. The treatment of psychotic depression: is there consensus among guidelines and psychiatrists? J Affect Disord 2013; 145:214.
- Honkola J, Hookana E, Malinen S, et al. Psychotropic medications and the risk of sudden cardiac death during an acute coronary event. Eur Heart J 2012; 33:745.
- Wijkstra J, Lijmer J, Balk FJ, et al. Pharmacological treatment for unipolar psychotic depression: Systematic review and meta-analysis. Br J Psychiatry 2006; 188:410.
- Farahani A, Correll CU. Are antipsychotics or antidepressants needed for psychotic depression? A systematic review and meta-analysis of trials comparing antidepressant or antipsychotic monotherapy with combination treatment. J Clin Psychiatry 2012; 73:486.
- Wijkstra J, Lijmer J, Burger H, et al. Pharmacological treatment for psychotic depression. Cochrane Database Syst Rev 2015; :CD004044.
- FDA Executive Summary: Prepared for the January 27-28, 2011 meeting of the Neurological Devices Panel. Meeting to Discuss the Classification of Electroconvulsive Therapy Devices (ECT). http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/NeurologicalDevicesPanel/UCM240933.pdf (Accessed on May 25, 2011).
- UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361:799.
- Kho KH, van Vreeswijk MF, Simpson S, Zwinderman AH. A meta-analysis of electroconvulsive therapy efficacy in depression. J ECT 2003; 19:139.
- American Psychiatric Association Task Force on Electroconvulsive Therapy. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. American Psychiatric Association, Washington, DC 2001.
- Petrides G, Fink M, Husain MM, et al. ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. J ECT 2001; 17:244.
- Nordenskjöld A, von Knorring L, Engström I. Predictors of the short-term responder rate of Electroconvulsive therapy in depressive disorders--a population based study. BMC Psychiatry 2012; 12:115.
- Blumberger DM, Mulsant BH, Emeremni C, et al. Impact of prior pharmacotherapy on remission of psychotic depression in a randomized controlled trial. J Psychiatr Res 2011; 45:896.
- Flint AJ, Rifat SL. The treatment of psychotic depression in later life: a comparison of pharmacotherapy and ECT. Int J Geriatr Psychiatry 1998; 13:23.
- Price LH, Conwell Y, Nelson JC. Lithium augmentation of combined neuroleptic-tricyclic treatment in delusional depression. Am J Psychiatry 1983; 140:318.
- Birkenhäger TK, van den Broek WW, Wijkstra J, et al. Treatment of unipolar psychotic depression: an open study of lithium addition in refractory psychotic depression. J Clin Psychopharmacol 2009; 29:513.
- Gaudiano BA, Miller IW, Herbert JD. The treatment of psychotic major depression: is there a role for adjunctive psychotherapy? Psychother Psychosom 2007; 76:271.
- Bach P, Guadiano BA, Pankey J et al. Acceptance, mindfulness values and psychosis: applying Acceptance and Commitment Therapy (ACT) to the chronically mentally ill, in Mindfulness-Based Treatment Approaches: Clinician’s Guide to Evidence Base and Applications. Edited by Baer RA, New York, Academic Press 2006. p 93.
- Gaudiano BA, Nowlan K, Brown LA, et al. An open trial of a new acceptance-based behavioral treatment for major depression with psychotic features. Behav Modif 2013; 37:324.
- Coryell W, Keller M, Lavori P, Endicott J. Affective syndromes, psychotic features, and prognosis. I. Depression. Arch Gen Psychiatry 1990; 47:651.
- Tohen M, Strakowski SM, Zarate C Jr, et al. The McLean-Harvard first-episode project: 6-month symptomatic and functional outcome in affective and nonaffective psychosis. Biol Psychiatry 2000; 48:467.
- Tohen M, Hennen J, Zarate CM Jr, et al. Two-year syndromal and functional recovery in 219 cases of first-episode major affective disorder with psychotic features. Am J Psychiatry 2000; 157:220.
- Coryell W, Leon A, Winokur G, et al. Importance of psychotic features to long-term course in major depressive disorder. Am J Psychiatry 1996; 153:483.
- Murphy E. The prognosis of depression in old age. Br J Psychiatry 1983; 142:111.
- Rothschild AJ, Schatzberg AF. Psychotic Depression: A newly recognized subtype. Clin Neurosci 1993; 1:75.
- General principles
- First line
- - Choosing a treatment
- - Antidepressant plus antipsychotic
- Choosing a combination
- Duration of therapy and switching drugs
- Evidence of efficacy
- - Electroconvulsive therapy
- Resistant patients
- - Lithium
- - Psychotherapy
- Refractory patients
- Family support
- TIME TO RECOVERY
- Functional recovery
- SUMMARY AND RECOMMENDATIONS