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The validity of the severity-psychosis hypothesis in depression

BACKGROUND

Psychotic depression (PD) is classified as a subtype of severe depression in the current diagnostic manuals. Accordingly, it is a common conception among psychiatrists that psychotic features in depression arise as a consequence of depressive severity. The aim of this study was to determine whether the severity of depressive and psychotic symptoms correlate in accordance with this "severity-psychosis" hypothesis and to detect potential differences in the clinical features of PD and non-psychotic depression (non-PD).

METHODS

Quantitative analysis of Health of the Nation Outcome Scales (HoNOS) scores from all patients admitted to a Danish general psychiatric hospital due to a severe depressive episode in the period between 2000 and 2010 was performed.

RESULTS

A total of 357 patients with severe depression, of which 125 (35%) were of the psychotic subtype, formed the study sample. Mean HoNOS scores at admission differed significantly between patients with non-PD and PD on the items hallucinations and delusions (non-PD=0.33 vs. PD=1.37, p<0.001), aggression (non-PD=0.20 vs. PD=0.36, p=0.044) and on the total score (non-PD=10.55 vs. PD=11.87, p=0.024). The HoNOS scores on the two items "depression" and "hallucinations and delusions" were very weakly correlated.

LIMITATIONS

Diagnoses were based on normal clinical practice and not formalized research criteria.

CONCLUSIONS

The symptomatology of PD and non-PD differs beyond the mere psychosis. Furthermore, severity ratings of depressive and psychotic symptoms are very weakly correlated. These findings offer further support to the hypothesis stating that the psychotic- and non-psychotic subtypes of depression may in fact be distinct clinical syndromes.

Persistence with polypharmacy and excessive dosing in patients with schizophrenia treated in four European countries

The purpose of this study was to calculate the proportion of patients with schizophrenia receiving persistent antipsychotic polypharmacy and excessive dosing in four European countries; to test the hypothesis that excessive dosing and/or antipsychotic polypharmacy is associated with higher levels of psychopathology; and to establish whether use of second-generation antipsychotics is a protective or a risk factor for polypharmacy and excessive dosing. Participants with schizophrenia were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (Netherlands), and Leipzig (Germany). We defined patients persistently receiving high antipsychotic dose (i.e. excessive dosing) as those with a prescribed daily dose/defined daily dose ratio of >1.5 both at initial assessment and after 1 year of follow-up. Similarly, we defined patients persistently receiving polypharmacy as those being prescribed two or more antipsychotic drugs both at baseline and at follow-up. A sample of 375 participants with schizophrenia was analyzed. A proportion of 28% of patients persistently received high-dose antipsychotic drugs, and a proportion of 13% of patients persistently received antipsychotic polypharmacy. In the multivariate analysis, psychopathology was not a predictor of persistent polypharmacy and excessive dosing; similarly, use of second-generation antipsychotics was not associated with polypharmacy and excessive dosing; however, persistence with high antipsychotic doses was predicted by baseline use of first-generation antipsychotics and second-generation antipsychotics concurrently. Antipsychotic drug use for patients with schizophrenia is only sometimes satisfactory and offers the opportunity of improvement. Clinicians should consider that dose reduction strategies have been shown to be a feasible intervention in patients with schizophrenia.