Unipolar major depression with psychotic features: Maintenance treatment and course of illness
- 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 maintenance treatment and prognosis of unipolar major depression with psychotic features. Acute treatment is discussed elsewhere, as are the epidemiology, pathogenesis, clinical features, assessment, and diagnosis of psychotic depression. (See "Unipolar major depression with psychotic features: Acute treatment" and "Unipolar major depression with psychotic features: Epidemiology, clinical features, assessment, and diagnosis".)
Unipolar major depression with psychotic features — 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. (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.
- 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.
- Aronson TA, Shukla S, Hoff A. Continuation Therapy After ECT for Delusional Depression: A Naturalistic Study of Prophylactic Treatments and Relapse. Convuls Ther 1987; 3:251.
- Rothschild AJ, Duval SE. How long should patients with psychotic depression stay on the antipsychotic medication? J Clin Psychiatry 2003; 64:390.
- Wijkstra J, Burger H, van den Broek WW, et al. Long-term response to successful acute pharmacological treatment of psychotic depression. J Affect Disord 2010; 123:238.
- Flint AJ, Rifat SL. Two-year outcome of psychotic depression in late life. Am J Psychiatry 1998; 155:178.
- 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).
- Østergaard SD, Meyers BS, Flint AJ, et al. Measuring psychotic depression. Acta Psychiatr Scand 2014; 129:211.
- Østergaard SD, Pedersen CH, Uggerby P, et al. Clinical and psychometric validation of the psychotic depression assessment scale. J Affect Disord 2015; 173:261.
- Meyers BS, Klimstra SA, Gabriele M, et al. Continuation treatment of delusional depression in older adults. Am J Geriatr Psychiatry 2001; 9:415.
- Rothschild AJ. Challenges in the treatment of major depressive disorder with psychotic features. Schizophr Bull 2013; 39:787.
- Coryell W, Winokur G, Shea T, et al. The long-term stability of depressive subtypes. Am J Psychiatry 1994; 151:199.
- Kessing LV. Subtypes of depressive episodes according to ICD-10: prediction of risk of relapse and suicide. Psychopathology 2003; 36:285.
- 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.
- Prudic J, Olfson M, Marcus SC, et al. Effectiveness of electroconvulsive therapy in community settings. Biol Psychiatry 2004; 55:301.
- Coryell W, Zimmerman M, Pfohl B. Outcome at discharge and six months in major depression. The significance of psychotic features. J Nerv Ment Dis 1986; 174:92.
- Aronson TA, Shukla S, Hoff A, Cook B. Proposed delusional depression subtypes: preliminary evidence from a retrospective study of phenomenology and treatment course. J Affect Disord 1988; 14:69.
- Helms PM, Smith RE. Recurrent psychotic depression. Evidence of diagnostic stability. J Affect Disord 1983; 5:51.
- Spiker DG, Stein J, Rich CL. Delusional Depression and Electroconvulsive Therapy: One Year Later. Convuls Ther 1985; 1:167.
- Rothschild AJ, Schatzberg AF. Psychotic Depression: A newly recognized subtype. Clin Neurosci 1993; 1:75.
- Lykouras E, Christodoulou GN, Malliaras D. Type and content of delusions in unipolar psychotic depression. J Affect Disord 1985; 9:249.
- Gournellis R, Lykouras L, Fortos A, et al. Psychotic (delusional) major depression in late life: a clinical study. Int J Geriatr Psychiatry 2001; 16:1085.
- Angst F, Stassen HH, Clayton PJ, Angst J. Mortality of patients with mood disorders: follow-up over 34-38 years. J Affect Disord 2002; 68:167.
- Vythilingam M, Chen J, Bremner JD, et al. Psychotic depression and mortality. Am J Psychiatry 2003; 160:574.
- Osby U, Brandt L, Correia N, et al. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry 2001; 58:844.
- Harris EC, Barraclough B. Excess mortality of mental disorder. Br J Psychiatry 1998; 173:11.
- Coryell W, Tsuang MT. Primary unipolar depression and the prognostic importance of delusions. Arch Gen Psychiatry 1982; 39:1181.
- Black DW, Winokur G, Nasrallah A. Effect of psychosis on suicide risk in 1,593 patients with unipolar and bipolar affective disorders. Am J Psychiatry 1988; 145:849.