Psychotic (delusional) depression: a meta-analysis of physical treatments

A systematic review and meta-analysis of maintenance treatment for psychotic depression

PURPOSE

To perform a systematic review on the use of maintenance treatment to prevent relapse and recurrence in patients with psychotic unipolar or bipolar depression.

METHODS

We conducted an electronic search in December 2019 (and an updated search in July 2021) of four databases (PubMed, Embase, PsycINFO, and Cochrane) to identify controlled studies comparing the relapse rates of patients receiving maintenance treatment for psychotic unipolar depression and psychotic bipolar depression. A meta-analysis was made that included three studies comparing antidepressant (AD) and antipsychotic (AP) combination therapy with AD monotherapy. We used the GRADE tool to assess the quality of evidence.

RESULTS

We included five randomized controlled trials fulfilling the inclusion criteria, making three comparisons: (a) AD + AP versus AD monotherapy; (b) AD + AP versus AP monotherapy; (c) AD + electroconvulsive therapy versus AD monotherapy. The included studies only examined patients with psychotic unipolar depression. The largest included study reported a statistically significant advantage of AD + AP compared with AD monotherapy. We made a meta-analysis of the three studies comparing AD + AP combination therapy with AD monotherapy, which included 195 patients and 56 events. The meta-analysis did not show a statistically significant difference between these treatments.

CONCLUSIONS

Contrary to the finding of the largest study, we did not find a statistically significant difference between AD + AP combination therapy and AD monotherapy in the meta-analysis. There is insufficient evidence to support the superiority of any treatment modality as maintenance treatment for psychotic depression. Further studies are required.

Guidelines for the management of psychosis in the context of mood disorders

Psychotic episodes occur in a substantial proportion of patients suffering from major mood disorders (both unipolar and bipolar) at some point in their lives. The nature of these episodes is less well understood than the more common, non-psychotic periods of illness and hence their management is also less sophisticated. This is a concern because the risk of suicide is particularly high in this subtype of mood disorder and comorbidity is far more common. In some cases psychotic symptoms may be signs of a comorbid illness but the relationship of psychotic mood to other forms of psychosis and in particular its interactions with schizophrenia is poorly understood. Therefore, our targeted review draws upon extant research and our combined experience to provide clinical context and a framework for the management of these disorders in real-world practice - taking into consideration both biological and psychological interventions.

Pharmacological treatment for psychotic depression

BACKGROUND

Evidence is limited regarding the most effective pharmacological treatment for psychotic depression: monotherapy with an antidepressant, monotherapy with an antipsychotic, another treatment (e.g. mifepristone), or combination of an antidepressant plus an antipsychotic. This is an update of a review first published in 2005 and last updated in 2015.

OBJECTIVES

1. To compare the clinical efficacy of pharmacological treatments for patients with an acute psychotic depression: antidepressant monotherapy, antipsychotic monotherapy, mifepristone monotherapy, and the combination of an antidepressant plus an antipsychotic versus placebo and/or each other. 2. To assess whether differences in response to treatment in the current episode are related to non-response to prior treatment.

SEARCH METHODS

A search of the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR); Ovid MEDLINE (1950-); Embase (1974-); and PsycINFO (1960-) was conducted on 21 February 2020. Reference lists of all included studies and related reviews were screened and key study authors contacted.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that included participants with acute major depression with psychotic features, as well as RCTs consisting of participants with acute major depression with or without psychotic features, that reported separately on the subgroup of participants with psychotic features.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias in the included studies, according to criteria from the Cochrane Handbook for Systematic Reviews of Interventions. Data were entered into RevMan 5.1. We used intention-to-treat data. Primary outcomes were clinical response for efficacy and overall dropout rate for harm/tolerance. Secondary outcome were remission of depression, change from baseline severity score, quality of life, and dropout rate due to adverse effects. For dichotomous efficacy outcomes (i.e. response and overall dropout), risk ratios (RRs) with 95% confidence intervals (CIs) were calculated.  Regarding the primary outcome of harm, only overall dropout rates were available for all studies. If the study did not report any of the response criteria as defined above, remission as defined here could be used as an alternative. For continuously distributed outcomes, it was not possible to extract data from the RCTs.  MAIN RESULTS: The search identified 3947 abstracts, but only 12 RCTs with a total of 929 participants could be included in the review. Because of clinical heterogeneity, few meta-analyses were possible. The main outcome was reduction in severity (response) of depression, not of psychosis. For depression response, we found no evidence of a difference between antidepressant and placebo (RR 8.40, 95% CI 0.50 to 142.27; participants = 27, studies = 1; very low-certainty evidence) or between antipsychotic and placebo (RR 1.13, 95% CI 0.74 to 1.73; participants = 201, studies = 2; very low-certainty evidence). Furthermore, we found no evidence of a difference in overall dropouts with antidepressant (RR 1.24, 95% CI 0.34 to 4.51; participants = 27, studies = 1; very low-certainty evidence) or antipsychotic monotherapy (RR 0.79, 95% CI 0.57 to 1.08; participants = 201, studies = 2; very low-certainty evidence). No evidence suggests a difference in depression response (RR 2.09, 95% CI 0.64 to 6.82; participants = 36, studies = 1; very low-certainty evidence) or overall dropouts (RR 1.79, 95% CI 0.18 to 18.02; participants = 36, studies = 1; very low-certainty evidence) between antidepressant and antipsychotic. For depression response, low- to very low-certainty evidence suggests that the combination of an antidepressant plus an antipsychotic may be more effective than antipsychotic monotherapy (RR 1.83, 95% CI 1.40 to 2.38; participants = 447, studies = 4), more effective than antidepressant monotherapy (RR 1.42, 95% CI 1.11 to 1.80; participants = 245, studies = 5), and more effective than placebo (RR 1.86, 95% CI 1.23 to 2.82; participants = 148, studies = 2). Very low-certainty evidence suggests no difference in overall dropouts between the combination of an antidepressant plus an antipsychotic versus antipsychotic monotherapy (RR 0.79, 95% CI 0.63 to 1.01; participants = 447, studies = 4), antidepressant monotherapy (RR 0.91, 95% CI 0.55 to 1.50; participants = 245, studies = 5), or placebo alone (RR 0.75, 95% CI 0.48 to 1.18; participants = 148, studies = 2). No study measured change in depression severity from baseline, quality of life, or dropouts due to adverse events. We found no RCTs with mifepristone that fulfilled our inclusion criteria. Risk of bias is considerable: we noted differences between studies with regards to diagnosis, uncertainties around randomisation and allocation concealment, treatment interventions (pharmacological differences between various antidepressants and antipsychotics), and outcome criteria.

AUTHORS' CONCLUSIONS

Psychotic depression is heavily under-studied, limiting confidence in the conclusions drawn. Some evidence indicates that combination therapy with an antidepressant plus an antipsychotic is more effective than either treatment alone or placebo. Evidence is limited for treatment with an antidepressant alone or with an antipsychotic alone. Evidence for efficacy of mifepristone is lacking.

Psychotic Depression: Diagnosis, Differential Diagnosis, and Treatment

Psychotic depression was initially considered to be at one end of a continuum of severity of major depression. Subsequent experience demonstrated that psychosis is an independent trait that may accompany mood disorders of varying severity. While much has been learned about the impact of severe mood congruent delusions and hallucinations on the course and treatment response of depression, less is known about fleeting or mild psychosis, mood incongruent features, or psychotic symptoms that reflect traumatic experiences. Acute treatment of psychotic unipolar depression generally involves the combination of an antidepressant and an antipsychotic drug or electroconvulsive therapy. There is inadequate information about maintenance treatment of unipolar psychotic depression and acute and chronic treatment of psychotic bipolar disorder. Decision-making therefore still must rely in part on clinical experience.

Efficacy and safety of electroconvulsive therapy plus medication versus medication alone in acute mania: A meta-analysis of randomized controlled trials

Although some studies have reported the potential efficacy of electroconvulsive therapy (ECT) in the treatment of acute mania, there is no consensus on the matter. Therefore, we performed a meta-analysis to determine the efficacy and safety of ECT combination with medication (ECT-combo) vs. medication alone (Med-alone) in the treatment of acute mania. Randomized controlled trials (RCTs) of ECT-combo versus Med-alone in acute mania were searched in Chinese databases and English databases from their inceptions up to February 2020. Twelve RCTs (including 863 patients, n=863) met our criteria and were included into meta-analysis. The pooled results found that ECT-combo outperformed Med-alone in reducing manic symptoms from baseline to endpoint with a standardized mean difference of -3.50 (95% CI: -4.57, -2.44, p<0.00001). The significant difference occurred after 3-5 treatments or after a 1-week treatment. ECT-combo had significantly increased memory impairment compared to Med-alone. Apart from increased memory impairment in ECT-combo group (SMD=8.33; 95% CI: 2.73 to 25.45, p= 0.0002), no other statistically significant differences in side effects or drop-out rates were found between groups. The results of this meta-analysis suggest that ECT-combo was significantly superior to Med-alone in efficacy and well-tolerated as Med-alone in the acute treatment of mania. However, larger studies with randomized, double-blind design, and standardized treatment regimens are still warranted due to the high heterogeneity of studies included in the present meta-analysis.

Computational modeling of the monoaminergic neurotransmitter and male neuroendocrine systems in an analysis of therapeutic neuroadaptation to chronic antidepressant

Second-line depression treatment involves augmentation with one (rarely two) additional drugs, of chronic administration of a selective serotonin reuptake inhibitor (SSRI), which is the first-line depression treatment. Unfortunately, many depressed patients still fail to respond even after months to years of searching to find an effective combination. To aid in the identification of potentially effective antidepressant combinations, we created a computational model of the monoaminergic neurotransmitter (serotonin, norepinephrine, and dopamine), stress-hormone (cortisol), and male sex hormone (testosterone) systems. The model was trained via machine learning to represent a broad range of empirical observations. Neuroadaptation to chronic drug administration was simulated through incremental adjustments in model parameters that corresponded to key regulatory components of the neurotransmitter and neurohormone systems. Analysis revealed that neuroadaptation in the model depended on all of the regulatory components in complicated ways, and did not reveal any one or a few specific components that could be targeted in the design of antidepressant treatments. We used large sets of neuroadapted states of the model to screen 74 different drug and hormone combinations and identified several combinations that could potentially be therapeutic for a higher proportion of male patients than SSRIs by themselves.

Management of Treatment-Resistant Depression: Challenges and Strategies

Treatment-resistant depression (TRD) is a subset of Major Depressive Disorder which does not respond to traditional and first-line therapeutic options. There are several definitions and staging models of TRD and a consensus for each has not yet been established. However, in common for each model is the inadequate response to at least 2 trials of antidepressant pharmacotherapy. In this review, a comprehensive analysis of existing literature regarding the challenges and management of TRD has been compiled. A PubMed search was performed to assemble meta-analyses, trials and reviews on the topic of TRD. First, we address the confounds in the definitions and staging models of TRD, and subsequently the difficulties inherent in assessing the illness. Pharmacological augmentation strategies including lithium, triiodothyronine and second-generation antipsychotics are reviewed, as is switching of antidepressant class. Somatic therapies, including several modalities of brain stimulation (electroconvulsive therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy and deep brain stimulation) are detailed, psychotherapeutic strategies and subsequently novel therapeutics including ketamine, psilocybin, anti-inflammatories and new directions are reviewed in this manuscript. Our review of the evidence suggests that further large-scale work is necessary to understand the appropriate treatment pathways for TRD and to prescribe effective therapeutic options for patients suffering from TRD.

Computational Analysis of Therapeutic Neuroadaptation to Chronic Antidepressant in a Model of the Monoaminergic Neurotransmitter and Stress Hormone Systems

The clinical practice of selective serotonin reuptake inhibitor (SSRI) augmentation relies heavily on trial-and-error. Unfortunately, the drug combinations prescribed today fail to provide relief for many depressed patients. In order to identify potentially more effective treatments, we developed a computational model of the monoaminergic neurotransmitter and stress-steroid systems that neuroadapts to chronic administration of combinations of antidepressant drugs and hormones by adjusting the strengths of its transmitter-system components (TSCs). We used the model to screen 60 chronically administered drug/hormone pairs and triples, and identified as potentially therapeutic those combinations that raised the monoamines (serotonin, norepinephrine, and dopamine) but lowered cortisol following neuroadaptation in the model. We also evaluated the contributions of individual and pairs of TSCs to therapeutic neuroadaptation with chronic SSRI using sensitivity, correlation, and linear temporal-logic analyses. All three approaches revealed that therapeutic neuroadaptation to chronic SSRI is an overdetermined process that depends on multiple TSCs, providing a potential explanation for the clinical finding that no single antidepressant regimen alleviates depressive symptoms in all patients.

Are clinical delusions adaptive?

Delusions are symptoms of psychiatric disorders such as schizophrenia and dementia. By and large, delusions are characterized by their behavioral manifestations and defined as irrational beliefs that compromise good functioning. In this overview paper, we ask whether delusions can be adaptive notwithstanding their negative features. Can they be a response to a crisis rather than the source of the crisis? Can they be the beginning of a solution rather than the problem? Some of the psychological, psychiatric, and philosophical literature has recently suggested that they can. We consider different types of delusions and different ways in which they can be considered as adaptive: psychologically (e.g., by increasing wellbeing, purpose in life, intrapsychic coherence, or good functioning) and biologically (e.g., by enhancing genetic fitness). Although further research is needed to map the costs and benefits of adopting and maintaining delusional beliefs, a more nuanced picture of the role of delusions in people's lives has started to emerge.

This article is categorized under:

Philosophy > Representation

Philosophy > Knowledge and Belief

Neuroscience > Cognition

Psychotic major depression: challenges in clinical practice and research

Psychotic major depression is an under-researched and under-identified disorder. We highlight the major challenges both in clinical practice and in conducting research with people with this disorder. We also suggest which major issues need addressing to move treatment and knowledge of this disorder forward. Declaration of interest M.H. and A.H.Y. both report grants from the National Institute for Health Research (NIHR).

Computational Model of Antidepressant Response Heterogeneity as Multi-pathway Neuroadaptation

Current hypotheses cannot fully explain the clinically observed heterogeneity in antidepressant response. The therapeutic latency of antidepressants suggests that therapeutic outcomes are achieved not by the acute effects of the drugs, but rather by the homeostatic changes that occur as the brain adapts to their chronic administration. We present a computational model that represents the known interactions between the monoaminergic neurotransmitter-producing brain regions and associated non-monoaminergic neurotransmitter systems, and use the model to explore the possible ways in which the brain can homeostatically adjust to chronic antidepressant administration. The model also represents the neuron-specific neurotransmitter receptors that are known to adjust their strengths (expressions or sensitivities) in response to chronic antidepressant administration, and neuroadaptation in the model occurs through sequential adjustments in these receptor strengths. The main result is that the model can reach similar levels of adaptation to chronic administration of the same antidepressant drug or combination along many different pathways, arriving correspondingly at many different receptor strength configurations, but not all of those adapted configurations are also associated with therapeutic elevations in monoamine levels. When expressed as the percentage of adapted configurations that are also associated with elevations in one or more of the monoamines, our modeling results largely agree with the percentage efficacy rates of antidepressants and antidepressant combinations observed in clinical trials. Our neuroadaptation model provides an explanation for the clinical reports of heterogeneous outcomes among patients chronically administered the same antidepressant drug regimen.

The best drug treatment for psychotic depression: Antidepressants, antipsychotics or both combined? Commentary On… Cochrane Corner

Psychotic depression is a severe condition. Drug treatment (antipsychotics, antidepressants or the combination) or electroconvulsive therapy (ECT) are both effective. However, a 2005 Cochrane review of drug treatments could not find a clear benefit for combination treatment with antidepressant and antipsychotic medication over antidepressants alone. The current updated Cochrane review (2015) incorporated two larger studies and found evidence of superiority for combination treatment. The review was constrained by the small number of available studies and could not address key questions such as the relative merits of antipsychotics and/or antidepressants compared with ECT or ketamine in acute treatment, and which treatments are best for long-term maintenance and prevention of recurrence. However, the methodology used was rigorous and the review gives the best summary to date of the evidence, as well as providing a platform for informing future research.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility.

METHODS

Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSIONS

The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh.

INTERNATIONAL EXPERT ADVISORS

Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham.

AUSTRALIAN AND NEW ZEALAND EXPERT ADVISORS

Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.

Pharmacological treatment for psychotic depression

BACKGROUND

Evidence is limited regarding the most effective pharmacological treatment for psychotic depression: combination of an antidepressant plus an antipsychotic, monotherapy with an antidepressant or monotherapy with an antipsychotic. This is an update of a review first published in 2005 and last updated in 2009.

OBJECTIVES

1. To compare the clinical efficacy of pharmacological treatments for patients with an acute psychotic depression: antidepressant monotherapy, antipsychotic monotherapy and the combination of an antidepressant plus an antipsychotic, compared with each other and/or with placebo.2. To assess whether differences in response to treatment in the current episode are related to non-response to prior treatment.

SEARCH METHODS

A search of the Cochrane Central Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register (CCDANCTR) was carried out (to 12 April 2013). These registers include reports of randomised controlled trials from the following bibliographic databases: EMBASE (1970-), MEDLINE (1950-) and PsycINFO (1960-). Reference lists of all studies and related reviews were screened and key authors contacted.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that included participants with acute major depression with psychotic features, as well as RCTs consisting of participants with acute major depression with or without psychotic features, that reported separately on the subgroup of participants with psychotic features.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias in the included studies, according to the criteria of the Cochrane Handbook for Systematic Reviews of Interventions. Data were entered into RevMan 5.1. We used intention-to-treat data. For dichotomous efficacy outcomes, the risk ratio (RR) with 95% confidence intervals (CIs) was calculated. For continuously distributed outcomes, it was not possible to extract data from the RCTs. Regarding the primary outcome of harm, only overall dropout rates were available for all studies.

MAIN RESULTS

The search identified 3659 abstracts, but only 12 RCTs with a total of 929 participants could be included in the review. Because of clinical heterogeneity, few meta-analyses were possible. The main outcome was reduction of severity (response) of depression, not of psychosis.We found no evidence for the efficacy of monotherapy with an antidepressant or an antipsychotic.However, evidence suggests that the combination of an antidepressant plus an antipsychotic is more effective than antidepressant monotherapy (three RCTs; RR 1.49, 95% CI 1.12 to 1.98, P = 0.006), more effective than antipsychotic monotherapy (four RCTs; RR 1.83, 95% CI 1.40 to 2.38, P = 0.00001) and more effective than placebo (two identical RCTs; RR 1.86, 95% CI 1.23 to 2.82, P = 0.003).Risk of bias is considerable: there were differences between studies with regard to diagnosis, uncertainties around randomisation and allocation concealment, differences in treatment interventions (pharmacological differences between the various antidepressants and antipsychotics) and different outcome criteria.

AUTHORS' CONCLUSIONS

Psychotic depression is heavily understudied, limiting confidence in the conclusions drawn. Some evidence indicates that combination therapy with an antidepressant plus an antipsychotic is more effective than either treatment alone or placebo. Evidence is limited for treatment with an antidepressant alone or with an antipsychotic alone.

The structure of the geriatric depressed brain and response to electroconvulsive therapy

Electroconvulsive therapy (ECT) is the treatment of choice in severe geriatric depression. High remission rates may be influenced by specific brain morphology characteristic of geriatric depression. Our objective was to identify the relationship between brain structure, symptom profile, and ECT response. In a naturalistic cohort of 55 patients with a major depressive disorder, structural magnetic resonance imaging (MRI) was performed before ECT. Voxel-based morphometry was applied to determine regional differences in gray matter (GM) volume between patients and 23 matched healthy controls. Depressed patients with psychotic symptoms showed significantly higher remission rates and smaller regional GM volume of the left inferior frontal gyrus (IFG). Patients with late onset depression showed smaller regional GM volume of the bilateral lateral temporal cortex. Larger size of response in the whole patient group was related to smaller pretreatment regional GM volume of the right lateral temporal cortex, whereas faster speed of response was related to smaller pretreatment regional GM volume of the right IFG. ECT is most effective in depressed patients with psychotic symptoms. In this study the presence of psychotic symptoms was related to pretreatment smaller GM volume of the left IFG and bilateral temporal cortex. Smaller volume of the IFG pretreatment was related to faster treatment response, and smaller volume of the right lateral temporal cortex pretreatment was related to larger response to ECT. These results are possibly explained by the connectivity between these brain regions and an interconnected network that is particularly activated by the ECT-induced seizures.

Electroconvulsive therapy on severe obsessive-compulsive disorder comorbid depressive symptoms

Electroconvulsive therapy (ECT) is not currently used as a first-line treatment for obsessive-compulsive disorder (OCD). However, several related case reports have demonstrated that ECT seems to be effective for severe OCD, especially when first-line therapies have failed. In this study, we describe the courses, detailed parameters, effects, and follow-up information relating to three patients with severe OCD who were treated by modified bifrontal ECT after their first-line anti-OCD treatments pharmacotherapy, behavioral therapy, and cognitive behavioral therapy failed. The number of ECT procedures administered in each case is as follows: Case 1, eight; Case 2, three; and Case 3, four. In all three cases, the patients' depressive symptoms improved considerably after the ECT procedures. In addition, the condition of all three patients' OCD significantly improved and remained stable at regular follow-ups. ECT may play an effective role in treating severe OCD.

Pharmacological treatment for psychotic depression

BACKGROUND

Evidence is limited regarding the most effective pharmacological treatment for psychotic depression: combination of an antidepressant plus an antipsychotic, monotherapy with an antidepressant or monotherapy with an antipsychotic. This is an update of a review first published in 2005 and last updated in 2009.

OBJECTIVES

1. To compare the clinical efficacy of pharmacological treatments for patients with an acute psychotic depression: antidepressant monotherapy, antipsychotic monotherapy and the combination of an antidepressant plus an antipsychotic, compared with each other and/or with placebo.2. To assess whether differences in response to treatment in the current episode are related to non-response to prior treatment.

SEARCH METHODS

A search of the Cochrane Central Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register (CCDANCTR) was carried out (to 12 April 2013). These registers include reports of randomised controlled trials from the following bibliographic databases: EMBASE (1970-), MEDLINE (1950-) and PsycINFO (1960-). Reference lists of all studies and related reviews were screened and key authors contacted.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that included participants with acute major depression with psychotic features, as well as RCTs consisting of participants with acute major depression with or without psychotic features, that reported separately on the subgroup of participants with psychotic features.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias in the included studies, according to the criteria of the Cochrane Handbook for Systematic Reviews of Interventions. Data were entered into RevMan 5.1. We used intention-to-treat data. For dichotomous efficacy outcomes, the risk ratio (RR) with 95% confidence intervals (CIs) was calculated. For continuously distributed outcomes, it was not possible to extract data from the RCTs. Regarding the primary outcome of harm, only overall dropout rates were available for all studies.

MAIN RESULTS

The search identified 3659 abstracts, but only 12 RCTs with a total of 929 participants could be included in the review. Because of clinical heterogeneity, few meta-analyses were possible. The main outcome was reduction of severity (response) of depression, not of psychosis.We found no evidence for the efficacy of monotherapy with an antidepressant or an antipsychotic.However, evidence suggests that the combination of an antidepressant plus an antipsychotic is more effective than antidepressant monotherapy (three RCTs; RR 1.49, 95% CI 1.12 to 1.98, P = 0.006), more effective than antipsychotic monotherapy (four RCTs; RR 1.83, 95% CI 1.40 to 2.38, P = 0.00001) and more effective than placebo (two identical RCTs; RR 1.86, 95% CI 1.23 to 2.82, P = 0.003).Risk of bias is considerable: there were differences between studies with regard to diagnosis, uncertainties around randomisation and allocation concealment, differences in treatment interventions (pharmacological differences between the various antidepressants and antipsychotics) and different outcome criteria.

AUTHORS' CONCLUSIONS

Psychotic depression is heavily understudied, limiting confidence in the conclusions drawn. Some evidence indicates that combination therapy with an antidepressant plus an antipsychotic is more effective than either treatment alone or placebo. Evidence is limited for treatment with an antidepressant alone or with an antipsychotic alone.

Challenges in the treatment of major depressive disorder with psychotic features

Psychotic depression is associated with significant morbidity and mortality but is underdiagnosed and undertreated. In recent years, there have been several studies that have increased our knowledge regarding the optimal treatment of patients with psychotic depression. The combination of an antidepressant and antipsychotic is significantly more effective than either antidepressant monotherapy or antipsychotic monotherapy for the acute treatment of psychotic depression. Most treatment guidelines recommend either the combination of an antidepressant with an antipsychotic or ECT for the treatment of an acute episode of unipolar psychotic depression. The optimal maintenance treatment after a person responds to either the antidepressant/antipsychotic combination or the ECT is unclear particularly as it pertains to length of time the patient needs to take the antipsychotic medication. Little is known regarding the optimal treatment of a patient with bipolar disorder who has an episode of psychotic depression or the clinical characteristics of responders to medication treatments vs ECT treatments.

An open trial of a new acceptance-based behavioral treatment for major depression with psychotic features

Research suggests that cognitive and behavioral therapies produce significant benefits over medications alone in the treatment of severe, nonpsychotic major depression or primary psychotic disorders such as schizophrenia. However, previous research has not demonstrated the efficacy of psychotherapy for major depression with psychotic features. In this initial treatment development study, we conducted an open trial of a new behavioral intervention that combines elements of behavioral activation and acceptance and commitment therapy for depression and psychosis. Fourteen patients with major depressive disorder with psychotic features were provided with up to 6 months of Acceptance-Based Depression and Psychosis Therapy (ADAPT) in combination with pharmacotherapy. Patients reported a high degree of treatment credibility and acceptability. Results showed that patients achieved clinically significant and sustained improvements through posttreatment follow-up in depressive and psychotic symptoms, as well as psychosocial functioning. In addition, the processes targeted by the intervention (e.g., acceptance, mindfulness, values) improved significantly over the course of treatment, and changes in processes were correlated with changes in symptoms. Results suggest that ADAPT combined with pharmacotherapy is a promising treatment approach for psychotic depression that should be tested in a future randomized trial.

Altered brain function underlying verbal memory encoding and retrieval in psychotic major depression

Psychotic major depression (PMD) is associated with deficits in verbal memory as well as other cognitive impairments. This study investigated brain function in individuals with PMD during a verbal declarative memory task. Participants included 16 subjects with PMD, 15 subjects with non-psychotic major depression (NPMD) and 16 healthy controls (HC). Functional magnetic resonance imaging (fMRI) data were acquired while subjects performed verbal memory encoding and retrieval tasks. During the explicit encoding task, subjects semantically categorized words as either "man-made" or "not man-made." For the retrieval task, subjects identified whether words had been presented during the encoding task. Functional MRI data were processed using SPM5 and a group by condition ANOVA. Clusters of activation showing either a significant main effect of group or an interaction of group by condition were further examined using t-tests to identify group differences. During the encoding task, the PMD group showed lower hippocampus, insula, and prefrontal activation compared to HC. During the retrieval task, the PMD group showed lower recognition accuracy and higher prefrontal and parietal cortex activation compared to both HC and NPMD groups. Verbal retrieval deficits in PMD may be associated with deficient hippocampus function during encoding. Increased brain activation during retrieval may reflect an attempt to compensate for encoding deficits.

Psychopharmacologic management of aggression

This article is designed to provide an overview of the existing literature on pharmacologically managing aggression, with a specific focus on psychiatric diagnoses commonly associated with increased aggression. Self-injurious behaviors and suicide are sometimes classified as forms of aggression, but information presented here focuses primarily on aggression toward others (physical and/or verbal).

Psychotic depression--beyond the antidepressant/antipsychotic combination

Psychotic depression is an identified subtype of major depression that has many features of a distinct psychiatric disorder. Recent studies support previous findings that psychotic depression is associated with a less favorable course of illness. Moreover, the presence of a single psychotic symptom appears to predict decreased responsiveness to antidepressant monotherapy. Recent studies also support biological differences between psychotic and non-psychotic depression. Previous findings of greater HPA axis dysregulation are supported by evidence of diminished cortisol suppression with the mineralocorticoid antagonist fludrocortisone in psychotic depression. Moreover, a functional neuroimaging study demonstrated greater activation in parahippocampal and tempoparietal regions in psychotic depression during a memory task. In support of several previous treatment studies, a recent meta-analysis of studies that compared an antidepressant-antipsychotic combination to antidepressants or antipsychotics alone found a therapeutic advantage with the combined treatment over monotherapy. A recent clinical trial suggests that mifepristone, a glucocorticoid antagonist, may be an effective adjunctive treatment for psychotic depression.

Meta-review of depressive subtyping models

BACKGROUND

Increasing dissatisfaction with the non-specificity of major depression has led many to propose more specific depressive subtyping models. The present meta-review seeks to map dominant depressive subtype models, and highlight definitions and overlaps.

METHODS

A database search in Medline and EMBASE of proposed depressive subtypes, and limited to reviews published between 2000 and 2011, was undertaken. Of the more than four thousand reviews, 754 were judged as potentially relevant and provided the base for the present selective meta-review.

RESULTS

Fifteen subtype models were identified. The subtypes could be divided into five molar categories of (1) symptom-based subtypes, such as melancholia, psychotic depression, atypical depression and anxious depression, (2) aetiologically-based subtypes, exemplified by adjustment disorders, early trauma depression, reproductive depression, perinatal depression, organic depression and drug-induced depression, (3) time of onset-based subtypes, as illustrated by early and late onset depression, as well as seasonal affective disorder, (4) gender-based (e.g. female) depression, and (5) treatment resistant depression. An overview considering definition, bio-psycho-social correlates and the evidence base of treatment options for each subtype is provided.

LIMITATIONS

Despite the large data base, this meta-review is nevertheless narrative focused.

CONCLUSIONS

Subtyping depression is a promising attempt to overcome the non-specificity of many diagnostic constructs such as major depression, both in relation to their intrinsic non-specificity and failure to provide treatment-specific information. If a subtyping model is to be advanced it would need, however, to demonstrate differential impacts of causes and treatments.

Minocycline as adjunctive therapy for patients with unipolar psychotic depression: an open-label study

BACKGROUND

Approximately 25% of patients admitted to a hospital as a result of depression are actually suffering from psychotic depression. Psychotic symptoms can be present in patients with either unipolar depression or bipolar depression and can be difficult to treat. It was reported the second-generation tetracycline may exert potential antidepressant effects through its robust neuroprotective activities, which include neurogenesis, antioxidation, and anti-glutamate excitotoxicity, and may direct regulation of pro-inflammatory agents.

METHODS

This was a 6-week, open-label study to evaluate the efficacy and safety of minocycline in combination with antidepressants in adult inpatients (n=25) diagnosed with major depression with psychotic features (psychotic depression) according to DSM-IV-TR. The primary endpoint was the change from baseline in the Hamilton Depression Rating Scale (HAM-D-21) score from baseline to week 6. Secondary endpoints were changes in the Brief Psychiatric Rating Scale (BPRS) and the Clinical Global Impression (CGI) Scale scores from baseline to week 6. Spontaneously reported adverse events were recorded.

RESULTS

The patients' average age was 46.9±10.2 years. Minocyline (150 mg/day) in combination with antidepressants (fulvoxamine, paroxetine, and sertraline) provided significant improvement in depression. Mean (± SD) HAM-D-21 was reduced to 6.7±1.9 at week 6 from a baseline value of 40.4±2.5. Significant improvement of psychotic symptoms (mean±SD) was indicated by the decrease in BPRS scores from baseline (63.3±8.7) to week 6 (4.6±2.4). No serious adverse events occurred.

CONCLUSIONS

These preliminary data suggest that minocycline in combination with antidepressants is effective and well tolerated in the treatment of unipolar psychotic depression. Further studies using larger, double-blind, parallel-group design are warranted to confirm these findings.

Major depressive disorder with psychotic features may lead to misdiagnosis of dementia: a case report and review of the literature

Major depressive disorder (MDD) with psychotic features is relatively frequent in patients with greater depressive symptom severity and is associated with a poorer course of illness and greater functional impairment than MDD without psychotic features. Multiple studies have found that patients with psychotic mood disorders demonstrate significantly poorer cognitive performance in a variety of areas than those with nonpsychotic mood disorders. The Mini Mental State Examination (MMSE) and the Dementia Rating Scale, Second Edition (DRS-2) are widely used to measure cognitive functions in research on MDD with psychotic features. Established total raw score cut-offs of 24 on the MMSE and 137 on the DRS-2 in published manuals suggest possible global cognitive impairment and dementia, respectively. Limited research is available on these suggested cut-offs for patients with MDD with psychotic features. We document the therapeutic benefit of electroconvulsive therapy (ECT), which is usually associated with short-term cognitive impairment, in a 68-year-old woman with psychotic depression whose MMSE and DRS-2 scores initially suggested possible global cognitive impairment and dementia. Over the course of four ECT treatments, the patient's MMSE scores progressively increased. After the second ECT treatment, the patient no longer met criteria for global cognitive impairment. With each treatment, depression severity, measured by the 24-item Hamilton Rating Scale for Depression, improved sequentially. Thus, the suggested cut-off scores for the MMSE and the DRS-2 in patients with MDD with psychotic features may in some cases produce false-positive indications of dementia.

Phenylbutyric acid prevents rats from electroconvulsion-induced memory deficit with alterations of memory-related proteins and tau hyperphosphorylation

Electroconvulsive therapy has been commonly applied in the treatment of refractory depression, but its cognitive side effects are noticed and restrict its application. The molecular mechanisms underlying the side effects remain elusive, and there is no efficient prevention. By employing a recognized electroconvulsive shock (ECS) rat model, we found in the present study that ECS induced spatial memory deficits with simultaneous decreases in synaptic proteins of N-methyl-D-aspartate receptor 2A/B (NR2A/B) and postsynaptic density 95 (PSD95), the immediate early gene c-Fos and cAMP response element binding (CREB) proteins, all of which are memory-related proteins. ECS also caused tau hyperphosphorylation at multiple Alzheimer-related phosphorylation sites with activation of glycogen synthase kinase-3beta (GSK-3beta), Akt and phospho-PKR-like endoreticulum (PERK), and inhibition of protein phosphatase-2A (PP)-2A. Intraperitoneal injection of phenylbutyric acid (PBA), an aromatic short chain fatty acid with the functions of molecule chaperon, prevented rats from the ECS-induced memory deficits, alterations of the memory-associated proteins, and tau hyperphosphorylation. Our data suggest that PBA may be potentially used for attenuating the side effects caused by electroconvulsive therapy.

Treatment of unipolar psychotic depression: the use of evidence in practice guidelines

INTRODUCTION

In a recent meta-analysis we found no evidence that an antidepressant plus an antipsychotic is more effective than an antidepressant alone in unipolar psychotic depression. However, most current guidelines recommend the combination over an antidepressant alone.

METHOD

We assessed available guidelines by the AGREE instrument and discuss their recommendations in relation to the evidence as referred to in the guidelines.

RESULTS

The UK-NICE guideline had the highest AGREE quality score, followed by the Dutch, Australian, and US-APA guidelines. Guidelines are not always consistent with at date of publication available evidence and (with exception of the UK-NICE and Dutch guidelines) also not with the in that guideline referred evidence.

CONCLUSION

Physicians (and patients) should be aware that in guidelines treatment recommendations may be less evidence-based than asserted, even when treatment recommendations are stated as being based on the highest level of evidence.

Treatment of unipolar psychotic depression: a randomized, double-blind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine

OBJECTIVE

It remains unclear whether unipolar psychotic depression should be treated with an antidepressant and an antipsychotic or with an antidepressant alone.

METHOD

In a multi-center RCT, 122 patients (18-65 years) with DSM-IV-TR psychotic major depression and HAM-D-17 > or = 18 were randomized to 7 weeks imipramine (plasma-levels 200-300 microg/l), venlafaxine (375 mg/day) or venlafaxine-quetiapine (375 mg/day, 600 mg/day). Primary outcome was response on HAM-D-17. Secondary outcomes were response on CGI and remission (HAM-D-17).

RESULTS

Venlafaxine-quetiapine was more effective than venlafaxine with no significant differences between venlafaxine-quetiapine and imipramine, or between imipramine and venlafaxine. Secondary outcomes followed the same pattern.

CONCLUSION

That unipolar psychotic depression should be treated with a combination of an antidepressant and an antipsychotic and not with an antidepressant alone, can be considered evidence based with regard to venlafaxine-quetiapine vs. venlafaxine monotherapy. Whether this is also the case for imipramine monotherapy is likely, but cannot be concluded from the data.

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)

CONTEXT

Evidence for the efficacy of combination pharmacotherapy has been limited and without positive trials in geriatric patients with major depression (MD) with psychotic features.

OBJECTIVES

To compare remission rates of MD with psychotic features in those treated with a combination of atypical antipsychotic medication plus a serotonin reuptake inhibitor with those treated with antipsychotic monotherapy; and to compare response by age.

DESIGN

Twelve-week, double-blind, randomized, controlled trial.

SETTING

Clinical services of 4 academic sites. Patients Two hundred fifty-nine subjects with MD with psychotic features randomized by age (<60 or > or =60 years) (mean [standard deviation (SD)], 41.3 [10.8] years in 117 younger adults vs 71.7 [7.8] years in 142 geriatric participants). Intervention Target doses of 15 to 20 mg of olanzapine per day plus masked sertraline or placebo at 150 to 200 mg per day. Main Outcome Measure Remission rates of MD with psychotic features.

RESULTS

Treatment with olanzapine/sertraline was associated with higher remission rates during the trial than olanzapine/placebo (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.12-1.47; P < .001); 41.9% of subjects who underwent combination therapy were in remission at their last assessment compared with 23.9% of subjects treated with monotherapy (chi(2)(1) = 9.53, P = .002). Combination therapy was comparably superior in both younger (OR, 1.25; 95% CI, 1.05-1.50; P = .02) and older (OR, 1.34; 95% CI, 1.09-1.66; P = .01) adults. Overall, tolerability was comparable across age groups. Both age groups had significant increases in cholesterol and triglyceride concentrations, but statistically significant increases in glucose occurred only in younger adults. Younger adults gained significantly more weight than older subjects (mean [SD], 6.5 [6.6] kg vs 3.3 [4.9] kg, P = .001).

CONCLUSIONS

Combination pharmacotherapy is efficacious for the treatment of MD with psychotic features. Future research must determine the benefits vs risks of continuing atypical antipsychotic medications beyond 12 weeks.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00056472.

Prevalence and clinical characteristics of psychotic versus nonpsychotic major depression in a general psychiatric outpatient clinic

BACKGROUND

Psychotic major depression (PMD) is a severe mental disorder characterized by high levels of illness severity, chronicity, impairment, and treatment resistance. However, most past research on PMD has been conducted in inpatient hospital samples, and relatively little is known about PMD patients presenting for treatment in the community specifically.

METHODS

In this study, we examined the prevalence and clinical characteristics of PMD in a large sample (n=2,500) of treatment-seeking outpatients who were administered structured clinical interviews by trained diagnosticians.

RESULTS

Of the patients diagnosed with major depression, 5.3% had psychotic features. PMD patients were more likely to be members of a racial/ethnic minority and to have lower educational attainment compared to those with nonpsychotic major depression. In addition, PMD patients were found to have greater current depression severity, suicidal ideation, and social and work impairment. These patients also were more likely to have histories of suicide attempts and psychiatric hospitalizations, to report an earlier age of illness onset, and to meet criteria for chronic depression. In terms of psychiatric comorbidity, PMD patients had higher rates of certain anxiety disorders as well as more somatoform and cluster A personality disorders.

CONCLUSIONS

Results indicated that PMD was present in a relatively small percentage of treatment-seeking outpatients but was associated with disproportionately high levels of severity and impairment. Similarities and differences between the current findings and those from past research are discussed, including clinical implications for the identification and treatment of PMD in routine practice settings.

How should mood disorders be modelled?

Classification of any mental disorder is likely to have clinical utility only if it is based on a valid underlying model. The depressive disorders have long provoked debates as to whether a categorical or a dimensional model is all explanatory. This paper will argue that no single (categorical or dimensional) model is likely to be valid, and that a mix of models is required to classify, diagnose and shape management decisions for the mood disorders. After reviewing limitations to the dimensionally based official classificatory systems (DSM-IV and ICD-10), and noting some of the consequences, a set of alternative strategies is outlined. In essence, identifying syndromal 'fuzzy sets' from phenotypic and aetiological clustering, a model that occurs in the rest of medicine.

Olanzapine in the treatment of depression with psychotic features: A prospective open-label study

Objective. Depression with psychotic features is a severe subtype of major depression associated with the presence of delusions, hallucinations and specific neurobiological features. Despite clinical consensus and guideline recommendations, data comparing the efficacy of combining antipsychotics with antidepressants compared to antidepressants alone remain inconclusive. The aim of the study was to investigate effectiveness and tolerability of the atypical antipsychotic olanzapine in acute depression with psychotic features. Methods. Seventeen inpatients with major depressive disorder with psychosis (MDDp) were treated with a combination of an antidepressant and olanzapine for 6 weeks in a prospective open-label study. Depressive and psychotic symptoms, extrapyramidal and general side effects were assessed every 2 weeks. Sixteen patients were eligible for final analysis. Results. The Brief Psychiatric Rating Scale (BPRS) showed a 30% symptom reduction after week 2, a 45% symptom reduction after week 4 and no considerable improvement thereafter. Depressive symptoms (Bech-Rafaelsen Melancholia Scale, BRMS) receded by 37% after week 2 and 50% after week 4. No extrapyramidal side effects occurred. Conclusion. Olanzapine is effective and tolerable in combination with an antidepressant in an MDDp inpatient sample. The results concur with data supporting good efficacy in negative and depressive symptoms of patients with schizophrenic and schizoaffective diseases.

First-episode psychosis: an epidemiological survey comparing psychotic depression with schizophrenia

BACKGROUND

Compared with non-psychotic depression, psychotic depression is associated with poor prognosis, increased mortality, and severe symptomatology. Although the incidence of psychotic depression is similar to that of schizophrenia, little is known about presentation, course, costs and effects of treatment.

AIMS

To compare the incidence, course and treatment of first-episode psychotic depression with first-episode schizophrenia.

METHOD

An observational database was set up on all patients aged 16 and over with a first-episode psychosis living in a county in Northern England between October 1998 and October 2005. Data were collected at presentation and annual follow-up. Information on patients with an ICD-10 diagnosis of either psychotic depression (F32.3) or schizophrenia (F20) was compared.

RESULTS

Between 1998 and 2005 there was a higher incidence of psychotic depression than schizophrenia (p<0.05, 95% CI=1.09, 1.89, RR=1.44). More patients with psychotic depression self-harmed (p<0.01) and had physical health problems (p<0.01). Similar levels of hospitalisation were found in both groups. A consistent pharmacological treatment pattern was observed for patients with psychotic depression but only 18 out of 105 received ECT. All who received ECT responded well to this treatment.

LIMITATIONS

Data collection relied on information in patients' medical notes, which sometimes had gaps. There is a potential under-representation of patient numbers due to the study relying on referral by consultant psychiatrists.

CONCLUSIONS

Psychotic depression is a common and costly condition, but with no accepted best practice guidance for its management. More attention needs to be focused on this largely under-researched group.

The treatment of psychotic major depression: is there a role for adjunctive psychotherapy?

BACKGROUND

Psychotic depression is a relatively prevalent mood disorder associated with greater symptom severity, a poorer course of illness and higher levels of functional impairment compared with nonpsychotic depression. Separate lines of investigation suggest that various forms of cognitive-behavioral therapy are efficacious for treating severe forms of nonpsychotic depression as well as primary psychotic disorders. However, there currently are no empirically supported psychotherapies specifically designed for treating psychotic depression.

METHOD

We review the efficacy of current somatic treatments for the disorder and discuss the limited data to date on potentially useful psychotherapeutic approaches. In particular, we describe the clinical improvement observed in a subgroup of hospitalized patients with psychotic depression treated with Acceptance and Commitment Therapy as part of a larger clinical trial.

RESULTS

Pilot results demonstrated that Acceptance and Commitment Therapy was associated with clinically significant reductions in acute symptom severity and impairment compared with treatment as usual.

CONCLUSION

The findings suggest that patients with psychotic depression can benefit from psychotherapy. Clinical and research recommendations in this area are presented.

Defining melancholia: the primacy of psychomotor disturbance

OBJECTIVE

To argue that melancholia is a categorically distinct depressive condition, able to be differentiated from other depressive conditions by a neuropathological marker [observable psychomotor disturbance (PMD)] and having a differential response to various antidepressant treatments.

METHOD

The above statements are addressed by review of a wide body of research, which identified observable PMD as the cardinal marker of melancholia and developed the CORE measure as a strategy for assessing PMD and its severity. Properties of the CORE measure, including reliability, validity and treatment prediction, are overviewed.

RESULTS

A case is made for defining melancholia and a strategy for establishing its probability.

CONCLUSION

Melancholia is positioned as a categorical entity capable of being circumscribed by its cardinal feature of PMD.

Through a glass darkly: the disutility of the DSM nosology of depressive disorders

OBJECTIVE

To demonstrate that the dimension-weighted DSM-IV model for classifying the depressive disorders lacks utility.

METHOD

The logical flaws in classifying the depressive disorders with any severity-based model (which underpin both the DSM-IV and ICD-10 systems) are noted. Integral definitional limitations to the DSM-IV definition of key depressive disorders are identified. It is argued that the DSM-IV classificatory system lacks utility for providing information on etiology and preferential management strategies. An alternative subtyping model is considered.

RESULTS

It is asserted that, in practice, the DSM-IV model and criteria lack explanatory power and compromise research and clinical practice.

CONCLUSIONS

It is hoped that this article evokes wider debate about modelling and classifying the depressive disorders.

Risperidone in the treatment of psychotic depression

In the preset study, the authors investigated that effects of the antipsychotic drug risperidone on psychotic depression and examined the mechanism of risperidone to ameliorate psychotic depression. Fifteen patients met the DSM-IV criteria for major depressive disorder with psychotic features and the remaining five patients met those for bipolar I disorder (most recent episode depressed) with psychotic features (M/F: 8/12, age: 54+/-18). All patients were evaluated regarding their clinical improvement using the Hamilton Rating Scale for Depression (Ham-D), and Positive and Negative Syndrome Scale (PANSS). In addition, plasma concentrations of HVA and MHPG were analyzed by HPLC. Patients with a 50% or more improvement in Ham-D score were defined as responders. Three were prescribed risperidone alone, and the other 17 were administered risperidone as an addition to preexisting antidepressants or mood stabilizers. The preexisting antidepressants or mood stabilizers were as follows: paroxetine (6), lithium (3), valproic acid (3), clomipramine (2), fluvoxamine (1), amitriptyline (1), amoxapine (1). The average dose of risperidone was 1.8+/-0.5 mg/day. Eleven of twenty patients (55%) turned out to be responders 4 weeks after initiation of risperidone administration. No differences were observed between responders and nonresponders with respect to age, sex, Ham-D score before risperidone treatment, dose and plasma level of risperidone or its active metabolite, 9-hydroxyrisperidone. Plasma HVA levels before risperidone administration in responders were significantly higher than those in nonresponders. In addition, a significant correlation was observed between changes in plasma HVA level and the percentage improvement on Ham-D score. These results indicate that treatment with risperidone is effective to ameliorate psychotic depression, and the influence of risperidone on dopaminergic activity is associated with its efficacy.

Psychotic Major Depression

Numerous studies in the past three decades have characterised 'psychotic major depression', a subtype of major depression which is accompanied by delusions or other psychotic features. Evidence from phenomenological and neurobiological investigations indicates that this is a unique disorder with clinical and biological characteristics that are distinct from those of nonpsychotic depression and from other psychotic disorders. Treatment studies have provided evidence of small placebo effects and good responses to electroconvulsive therapy or combination treatment with an antidepressant plus an antipsychotic agent. However, until recently, there were only a few small, prospective, double-blind, controlled trials investigating the efficacy of antidepressant-antipsychotic combination pharmacotherapy, yet this constitutes the currently accepted and most universally applied 'standard of care' for psychotic depression. Treatment guidelines have been based largely on uncontrolled investigations of electroconvulsive therapy and studies using tricyclic antidepressants and first-generation antipsychotic drugs, which are not frequently chosen as first-line agents today because of concerns regarding tolerability and risks. However, recent open-label studies and large controlled trials of newer antidepressants and antipsychotics have yielded very divergent results thus far, so that the best treatment approach remains elusive. This review discusses the phenomenology and treatment of psychotic depression with a focus on the benefits and risks of various treatment approaches. Problems with this literature are highlighted, and strategies for future research are suggested.

One-year outcome of psychotic depression after successful electroconvulsive therapy

BACKGROUND

Psychotic depression is thought to have a higher relapse frequency after electroconvulsive therapy (ECT) compared with nonpsychotic depression, although this observation is contradicted by previous studies that have found the opposite. In this study, the 1-year risk of relapse after successful ECT was determined prospectively in patients with psychotic depression and compared with the risk of relapse observed for depressed patients without psychotic features.

METHOD

Fifty-nine responders to ECT (a decrease in Hamilton Rating Scale for Depression [HAM-D] score > or = 50%) were followed for 1 year: 29 with and 30 without psychotic features. Relapse was defined as meeting DSM-IV criteria for major depressive disorder and a HAM-D score > or = 16. The frequency of relapse after 4 and 12 months was compared between both samples, adjusted for the co-variables duration of the index episode and type of post-ECT pharmacotherapy.

RESULTS

: At both 4 and 12 months after ECT, instances of relapse were significantly lower in patients with psychotic depression compared with nonpsychotic patients: 3/28 (11%) versus 16/27 (59%) and 4/27 (15%) versus 19/28 (68%), respectively.

CONCLUSIONS

The main finding of the present study is the favorable 1-year outcome for patients with psychotic depression after response to ECT with a trend toward the same result at 4 months. The 1-year outcome of the total sample is also more favorable than expected.

Evidências da eficácia da eletroconvulsoterapia na prática psiquiátrica

A eletroconvulsoterapia (ECT) consiste em tratamento biológico ainda não amplamente utilizado na prática psiquiátrica, devido aos inúmeros fatores que contribuem para uma resistência acerca do método. Objetivando sustentar, com embasamento científico, o emprego da ECT, agregamos evidências de sua eficácia, indicações, contra-indicações e efeitos adversos, advindas dos principais ensaios clínicos randomizados e meta-análises disponíveis na literatura médica atual sobre o tema (PubMed/MEDLINE, Cochrane).

Pharmacological treatment for psychotic depression

BACKGROUND

Regarding the pharmacological treatment of psychotic depression there is uncertainty about the effectiveness of an antidepressant alone compared to the combination of an antidepressant and an antipsychotic.

OBJECTIVES

To compare the clinical effectiveness of pharmacological treatments for patients with a psychotic depression: antidepressant monotherapy, antipsychotic monotherapy, and the combination of an antidepressant and an antipsychotic, compared with each other and/or with placebo.

SEARCH STRATEGY

(1) The Cochrane Central Register of Controlled Trials (CENTRAL) was screened with the terms depressive disorder and drug treatment (April 2004). (2) MEDLINE (1966 to April 2004) and EMBASE (1980 to April 2004) were searched using terms with regard to treatment of unipolar psychotic depression.(3) Reference lists of related reviews and reference lists of all identified studies were searched.(4) Personal communications.

SELECTION CRITERIA

All randomised controlled trials (RCTs) with patients with major depression with psychotic features as well as RCTs with patients with major depression with or without psychotic features which reported on the subgroup of patients with psychotic features separately.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the methodological quality of the included studies, according to the Cochrane Handbook criteria. Data were entered into RevMan 4.2.5. We used intention-to-treat data. For dichotomous efficacy outcomes, the relative risk with 95% confidence intervals (CI) was calculated. For continuously distributed outcomes, it was not possible to extract data from the RCTs. Regarding the primary harm outcome, only overall drop-out rates were available for all studies.

MAIN RESULTS

The search identified 3333 abstracts, but only 10 RCTs with a total of 548 patients could be included in the review. Due to clinical heterogeneity, few meta-analyses were possible. We found no conclusive evidence that the combination of an antidepressant and an antipsychotic is more effective than an antidepressant alone (two RCTs; RR 1.44, 95% CI 0.86 to 2.41), but a combination is more effective than an antipsychotic alone (three RCTs; RR 1.92, 95% CI 1.32 to 2.80). There were no statistically significant differences in the overall drop-out rates between any of the treatments, neither in individual studies nor after pooling of studies.

AUTHORS' CONCLUSIONS

Treatment with an antipsychotic alone is not a good option. Starting with an antidepressant alone and adding an antipsychotic if the patient does not respond or starting with the combination of an antidepressant and an antipsychotic both appear appropriate options for patients with psychotic depression. In clinical practice the balance between risks and benefits suggests that initial antidepressive monotherapy and adding an antipsychotic if there is inadequate response should be the preferred treatment strategy for many patients. The general lack of available data limits confidence in the conclusions drawn.

The pharmacological management of depression

Depressive disorders are common, recurrent, and chronic, and require treatment A review of the symptom picture and current drug targets demonstrates the need for accument of depression severity, including suicidaliltial focus of treatment is rapid resolution of: during an acute phase, followed by continuation. Maintenance treatment is indicated if the risk of recurrence is high. The range of available medications is considerable and the benefit/risk ratio is acceptable. Depression is diagnosable across the life span and treatable at every age (although recent disagreement has arisen with regard to young patients). Comorbidity, both psychiatric and medical, need to be assessed, as does the possible presence of two subtypes of depression (psychotic and bipolar) often requiring different interventions. It is expected that the next generation of antidepressants would be associated with more specific disease and outcome biomarkers.

Identifying "paradigm failures" contributing to treatment-resistant depression

BACKGROUND

"Treatment resistant depression" is likely to emerge from a number of factors, including application of the wrong diagnostic and treatment models.

METHOD

Current paradigms for managing both depression and treatment resistant depression are considered. We then examine the prevalence of a set of paradigm failures that appeared to contribute to treatment resistant depression in outpatients of a tertiary referral Mood Disorders Unit.

RESULTS

Six illustrative paradigm failures are described and their frequencies within the clinical sample reported. Identified paradigm failures were diagnosing and/or managing a non-melancholic condition as if it were melancholic depression, failure to diagnose and manage bipolar disorder, psychotic depression or melancholic depression, misdiagnosing secondary depression and failure to identify organic determinants.

CONCLUSION

We suggest that the identification of such "paradigm failures"--and of others that can be assumed to operate--has the potential to enrich the assessment and management of depressed patients, and reduce the prevalence of treatment resistance.

Antidepressant treatment of psychotic major depression: potential role of the sigma receptor

Psychotic major depression is a severe condition that frequently proves difficult-to-treat. The most effective traditional treatments (electroconvulsive therapy and combinations of antipsychotics with tricyclic antidepressants) are associated with significant side effects, and the use of tricyclic antidepressants alone is largely ineffective. Recent evidence has indicated that the selective serotonin reuptake inhibitors, either alone or in combination with antipsychotics, may provide a desirable alternative to traditional treatments. Among selective serotonin reuptake inhibitors, fluvoxamine has been the best studied and, somewhat surprisingly, has proven effective in several studies as a monotherapy without the need to combine with an antipsychotic. It is proposed that the apparent efficacy of fluvoxamine in psychotic major depression may be related to its unique property of high affinity for the sigma 1 receptor, which is thought to play a role in psychosis and in the action of some antipsychotic drugs.

Structural and functional models of depression: from sub-types to substrates

OBJECTIVE

To present a functional model of depression facilitating research and clinical understanding.

METHOD

The authors conducted a systematic literature search and reviewed articles pertaining to the neurochemistry and pathophysiology of depressive disorders, focusing on the contribution made by the principal monoamines to three differing depressive structural sub-types (i.e. psychotic, melancholic and non-melancholic).

RESULTS

We suggest that the three structural depressive subtypes appear functionally underpinned by differential contributions of serotonergic, noradrenergic and dopaminergic neurotransmitters, so influencing phenotypic distinction (our structural model) and allowing an aetiological model to be derived with treatment specificity implications.

CONCLUSION

The functional model logically iterates with the structural model of depression and provides a useful framework for conceptualizing the depressive disorders. This model provides a logic for distinguishing between principal depressive subtypes, pursuing their functional underpinnings and explaining treatment differential effects across the three sub-types.

Antidepressive Stimulationsverfahren

Affective disorders, especially major depression, are the most common psychiatric disorders. Although well treatable, a number of patients do not or do not sufficiently respond to antidepressant pharmacotherapy. Therefore there is a need for safe and efficient alternative therapeutic strategies. Neurostimulatory therapies such as electroconvulsive therapy, repetitive transcranial magnetic stimulation, and vagus nerve stimulation belong to these alternatives. In this article we review their mechanisms of action and summarize efficacy and adverse effects.

Evaluating treatments for the mood disorders: time for the evidence to get real

OBJECTIVE

To detail limitations to level I evidence derived from randomised controlled trials of antidepressant treatments and which is held to be fundamental to the development and validity of treatment guidelines.

METHOD

Recent efficacy studies and meta-analyses of treatments of major depression are considered.

RESULTS

The largest database in psychiatry--demonstrating that all principal treatments are of similar efficacy, and that antidepressant drugs are not distinctly superior to placebo treatment--is unlikely to be valid.

CONCLUSION

Excessive belief in and weighting of the evidence emerging from randomised controlled trials deserves to be criticized. An argument is put for adopting alternative approaches to evaluating the likely effectiveness of any antidepressant treatment.

Modern diagnostic concepts of the affective disorders

OBJECTIVE

To review critically alternative models of depression.

METHOD

Contrasting historical models are noted and some results of a study overviewing a temperament-based model for the non-melancholic disorders are presented.

RESULTS

Limitations to all models are considered.

CONCLUSION

As depression can present as a mood state, a syndrome, a disorder and as a disease, it is unwise to assume that a single model will suffice. A pure temperament diathesis model of non-melancholic depression is unlikely to be sufficient and would benefit from testing of additional personality constructs.

Treatment of non-schizophrenic disorders: focus on atypical antipsychotics

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.