Psychotic (delusional) depression and completed suicide: a systematic review and meta-analysis

Variations in Suicide Risk and Risk Factors After Hospitalization for Depression in Finland, 1996-2017

Importance

Although incidence of suicide in depression varies remarkably temporally, risk factors have been modeled as constant and remain uncharted in the short term. How effectively factors measured at one point in time predict risk at different time points is unknown.

Objective

To examine the absolute risk and risk factors for suicide in hospitalized patients with depression starting from the first days after discharge up to 2 years and to evaluate whether the size of relative risk by factor displays temporal patterns over consecutive phases of follow-up.

Design, Setting, and Participants

This population-based study using Finnish registers (hospital discharge, population, and cause of death registers) included all hospitalizations for depression as the principal diagnosis in Finland from 1996 to 2017, with a maximum follow-up of 2 years. Data were analyzed from January 2022 to November 2023.

Main Outcomes and Measures

Incidence rate (IR), IR ratios, hazard functions, and hazard ratios for suicide by consecutive time periods (0 to 3 days, 4 to 7 days, 7 to 30 days, 31 to 90 days, 91 to 365 days, and 1 to 2 years) since discharge.

Results

This study included 193 197 hospitalizations among 91 161 individuals, of whom 51 197 (56.2%) were female, and the mean (SD) age was 44.0 (17.3) years. Altogether, patients were followed up to 226 615 person-years. A total of 1219 men and 757 women died of suicide. Incidence of suicide was extremely high during the first days after discharge (IR of 6062 [95% CI, 4963-7404] per 100 000 on days 0 to 3; IR of 3884 [95% CI, 3119-4835] per 100 000 on days 4 to 7) and declined thereafter. Several factors were associated with risk of suicide over the first days after discharge. Current suicide attempt by hanging or firearms increased the risk of suicide most on days 0 to 3 (IR ratio, 18.9; 95% CI, 3.1-59.8) and on days 0 to 7 (IR ratio, 10.1; 95% CI, 1.7-31.5). Temporal patterns of the size of the relative risk diverged over time, being constant, declining, or increasing. Clinical factors had the strongest association immediately. Relative risk remained constant among men and even increased among those with alcohol or substance use disorder.

Conclusions and Relevance

In this study, patients hospitalized for depression had extremely high risk of suicide during the first days after discharge. Thereafter, incidence declined steeply but remained high. Within the periods of the highest risk of suicide, several factors increased overall risk manyfold. Risk factors' observed potencies varied over time and had characteristic temporal patterns.

Serial multiple mediating roles of anxiety and thyroid-stimulating hormone in the relationship between depression and psychotic symptoms in young adults with anxious depression

BACKGROUND

Psychotic symptoms (PS) frequently occur in young adults with anxious depression (AD), yet the mediators of the associations between depression and PS remain unclear. This study aimed to investigate the prevalence and risk factors of PS in first-episode and drug-naïve (FEDN) young adults with AD and attempted to elucidate the relationship between thyroid-stimulating hormone (TSH) levels, anxiety, depression, and PS, as well as to identify potential mediating roles.

METHODS

369 FEDN young adults with AD were recruited. Clinical symptoms were assessed using the Positive and Negative Syndrome Scale's positive subscale, the Hamilton Depression Rating Scale (HAMD), and the Hamilton Anxiety Rating Scale (HAMA). Fasting glucose, lipids, and thyroid function were also collected.

RESULTS

The prevalence of PS in young adults with AD (21.68 %) was 12.24 times higher than in non-AD patients. The HAMD scores (P = 0.005, OR = 1.23), HAMA scores (P < 0.001, OR = 1.62), and TSH levels (P = 0.025, OR = 1.20) were significant predictors of PS. The combined area under the curve value for distinguishing young adults with AD with and without PS was 0.86. We also identified serial multiple mediating effects of TSH levels and anxiety on the association of depression with PS.

CONCLUSIONS

These findings emphasize the role of anxiety and TSH levels as serial mediators of the association between depression and PS. Therefore, when treating PS in young adults with AD, it is important to focus not only on depression, but also on TSH levels and anxiety to maximize benefit.

Interaction between HTR2A rs3125 and negative life events in suicide attempts among patients with major depressive disorder: a cross-sectional study

BACKGROUND

Both genetic and environmental factors play crucial roles in the development of major depressive disorder (MDD) and suicide attempts (SA). However, the interaction between both items remains unknown. This study aims to explore the interactions between the genetic variants of the serotonin 2 A receptor (HTR2A) and the nitric oxide synthase 1 (NOS1) and environmental factors in patients who experience MDD and SA.

METHODS

A total of 334 patients with MDD and a history of SA (MDD-SA) were recruited alongside 518 patients with MDD with no history of SA (MDD-NSA), and 716 healthy controls (HC). The demographic data and clinical characteristics were collected. Sequenom mass spectrometry was used to detect eight tag-single nucleotide polymorphisms (tagSNPs) in HTR2A (rs1328683, rs17068986, and rs3125) and NOS1 (rs1123425, rs2682826, rs3741476, rs527590, and rs7959232). Generalized multifactor dimensionality reduction (GMDR) was used to analyze the gene-environment interactions.

RESULTS

Four tagSNPs (rs17068986, rs3125, rs527590, and rs7959232) exhibited significant differences between the three groups. However, these differences were not significant between the MDD-SA and MDD-NSA groups after Bonferroni correction. A logistic regression analysis revealed that negative life events (OR = 1.495, 95%CI: 1.071-2.087, P = 0.018), self-guilt (OR = 2.263, 95%CI: 1.515-3.379, P < 0.001), and negative cognition (OR = 2.252, 95%CI: 1.264-4.013, P = 0.006) were all independently associated with SA in patients with MDD. Furthermore, GMDR analysis indicated a significant interaction between HTR2A rs3125 and negative life events. Negative life events in conjunction with the HTR2A rs3125 CG + GG genotype were associated with a higher SA risk in patients with MDD when compared to the absence of negative life events in conjunction with the CC genotype (OR = 2.547, 95% CI: 1.264-5.131, P = 0.009).

CONCLUSION

Several risk factors and a potential interaction between HTR2A rs3125 and negative life events were identified in patients with SA and MDD. The observed interaction likely modulates the risk of MDD and SA, shedding light on the pathogenesis of SA in patients with MDD.

Effect of olanzapine exposure on relapse and brain structure in patients with major depressive disorder with psychotic features

Some data suggest that antipsychotics may adversely affect brain structure. We examined the relationship among olanzapine exposure, relapse, and changes in brain structure in patients with major depressive disorder with psychotic features. We analyzed data from the Study of the Pharmacotherapy of Psychotic Depression II trial (STOP-PD II), a randomized, placebo-controlled trial in patients with psychotic depression who attained remission on sertraline and olanzapine and were randomized to continue sertraline plus olanzapine or placebo for 36 weeks. Olanzapine steady state concentration (SSC) were calculated based on sparsely-sampled levels. Rates of relapse and changes in brain structure were assessed as outcomes. There were significant associations between dosage and relapse rates (N = 118; HR = 0.94, 95% CI [0.897, 0.977], p = 0.002) or changes in left cortical thickness (N = 44; B = -2.0 × 10-3, 95% CI [-3.1 × 10-3, -9.6 × 10-4], p < 0.001) and between SSC and changes in left cortical thickness (N = 44; B = -8.7 × 10-4, 95% CI [-1.4 × 10-3, -3.6 × 10-4], p = 0.001). Similar results were found for the right cortex. These associations were no longer significant when the analysis was restricted to participants treated with olanzapine. Our findings suggest that, within its therapeutic range, the effect of olanzapine on relapse or cortical thickness does not depend on its dosage or SSC. Further research is needed on the effect of olanzapine and other antipsychotics on mood symptoms and brain structure.

Overview of late-onset psychoses

BACKGROUND

Several etiologies can underlie the development of late-onset psychosis, defined by first psychotic episode after age 40 years. Late-onset psychosis is distressing to patients and caregivers, often difficult to diagnose and treat effectively, and associated with increased morbidity and mortality.

METHODS

The literature was reviewed with searches in Pubmed, MEDLINE, and the Cochrane library. Search terms included "psychosis," "delusions," hallucinations," "late onset," "secondary psychoses," "schizophrenia," bipolar disorder," "psychotic depression," "delirium," "dementia," "Alzheimer's," "Lewy body," "Parkinson's, "vascular dementia," and "frontotemporal dementia." This overview covers the epidemiology, clinical features, neurobiology, and therapeutics of late-onset psychoses.

RESULTS

Late-onset schizophrenia, delusional disorder, and psychotic depression have unique clinical characteristics. The presentation of late-onset psychosis requires investigation for underlying etiologies of "secondary" psychosis, which include neurodegenerative, metabolic, infectious, inflammatory, nutritional, endocrine, and medication toxicity. In delirium, psychosis is common but controlled evidence is lacking to support psychotropic medication use. Delusions and hallucinations are common in Alzheimer's disease, and hallucinations are common in Parkinson's disease and Lewy body dementia. Psychosis in dementia is associated with increased agitation and a poor prognosis. Although commonly used, no medications are currently approved for treating psychosis in dementia patients in the USA and nonpharmacological interventions need consideration.

CONCLUSION

The plethora of possible causes of late-onset psychosis requires accurate diagnosis, estimation of prognosis, and cautious clinical management because older adults have greater susceptibility to the adverse effects of psychotropic medications, particularly antipsychotics. Research is warranted on developing and testing efficacious and safe treatments for late-onset psychotic disorders.

Clinical predictors of suicidal ideation, suicide attempts and suicide death in depressive disorder: a systematic review and meta-analysis

Patients with depressive disorders are especially prone to suicide risk. Among the clinical predictors of suicidality, those specifically related to depressive disorders have not been accurately detailed. Our aim was to conduct a systematic review and meta-analysis of studies reporting longitudinal predictors of suicidal ideation, suicide attempts and suicide death within depression, including diagnostic subtypes, symptoms, clinical course, and assessment scales. A systematic search of the literature between 2001 and 2022 identified 4422 references, among which 19 studies providing 45 different predictors of suicidality met the inclusion criteria. Random effects meta-analyses were performed for 22 predictors, three for suicidal ideation, eleven for suicide attempts and eight for suicide death. Heterogeneity and publication bias were inspected through I2 tests and Egger's tests respectively. Meta-analysis results showed that severity of hopelessness predicted suicidal ideation and suicide attempts. History of suicide attempts, suicidal ideation, severe depression, and psychotic symptoms predicted subsequent suicide attempts and suicide death. Time to full remission and sleep disturbances were also found as relevant predictors of future suicide behaviours. This review specifies which predictors of suicidality within the clinical features of depression will help clinicians and policy makers to better prevent suicide risk in patients with depressive disorders. Further longitudinal studies are needed to reliably assess the predictive ability of our results and to analyse other possible clinical predictors to prevent suicidality, especially with regard to suicidal ideation.

Use of antipsychotics and antidepressants in first-episode psychotic depression: A nationwide register-based study

BACKGROUND

According to guidelines, psychotic depression should be treated with both antipsychotics and antidepressants, but current practice is largely unknown. We investigated the prevalence of antipsychotic and antidepressant use in first-episode psychotic depression and factors related to antipsychotic use after the diagnosis.

METHODS

We identified individuals aged 16-65 with a first-episode diagnosis of psychotic depression (ICD-10 codes F32.3, F33.3) from nationwide data linkage of Finnish healthcare and population registers during 2000-2018. Point prevalence was measured as 2-week time windows every 3 months, investigating whether the individual had a modeled drug use period ongoing during the window or not, censoring to death and end of data linkage.

RESULTS

The study population included 18,490 individuals (58.0% women; mean age 39.9 years, standard deviation 14.7). The prevalence of use for antidepressants (75.0%), antipsychotics (56.4%), and both (50.0%) were highest at 3 months after the diagnosis. The prevalence declined to 51.8%, 34.1%, and 28.7%, respectively, at 3 years after the diagnosis. In a logistic regression analysis, younger age (adjusted odds ratio < 25 vs. ≥55, 0.82 [95% confidence interval 0.73-0.91]), eating disorders (0.78 [0.66-0.92]), substance use disorders (0.80 [0.73-0.87]), and occupational inactivity (0.80 [0.73-0.87]) were associated with decreased odds of using antipsychotics at 3 months after diagnosis. Increased odds were found for diagnosis from inpatient care (1.74 [1.62-1.86]), and later year of cohort entry (2010-2014 vs. 2000-2004, 1.56 [1.42-1.70]).

CONCLUSION

At most, half of the individuals with newly diagnosed psychotic depression used both antidepressants and antipsychotics. This likely has a negative impact on treatment success.

Prevalence and risk factors of suicide attempts in young, first-episode and drug-naïve Chinese Han outpatients with psychotic major depressive disorder

This study investigates the relationship between psychotic symptoms and suicide attempts in young first-episode, drug-naive Chinese Han outpatients diagnosed with Major Depressive Disorder (MDD). The prevalence of Psychotic Major Depressive Disorder (PMD) was found to be 8.3% among the enrolled MDD patients. The study assessed 1289 participants using various scales to evaluate the severity of clinical symptoms, including the CGI-S, the HAMD, the HAMA, and the PANSS positive subscale. Additionally, thyroid hormone and glucolipid metabolism indicators were examined. The findings indicate that among patients with PMD, 41.12% had recent suicide attempts, while 6.54% had previous suicide attempts. Patients who recently attempted suicide exhibited higher scores on the HAMA and CGI scales, along with elevated serum levels of Thyroid-Stimulating Hormone (TSH) and total cholesterol (TC), as well as higher systolic and diastolic blood pressure. Notably, TSH levels independently correlated with recent suicide attempts in PMD patients, with an impressive area under the receiver operating characteristic curve (AUROC) of 0.923. Furthermore, the subgroup of patients with previous suicide attempts displayed longer illness duration and higher HAMD scores. Duration of illness and HAMD were found to be independently associated with previous suicide attempts among PMD patients, with a combined predictive effect showing a robust AUROC of 0.910. In conclusion, this study highlights the significant prevalence of recent and previous suicide attempts among young Chinese Han outpatients with PMD. The identification of risk factors, especially the link between TSH levels and recent suicide attempts, offers valuable insights for clinicians to develop targeted interventions and preventive strategies for this vulnerable patient population.

The Arabic Questionnaire for Psychotic Experiences in patients with psychotic disorders: a clinical validation

BACKGROUND

Psychotic experiences are reported in the general population. The Questionnaire for Psychotic Experiences (QPE) was created to test the phenomenological features of these experiences and compare them with those reported in patients with psychiatric and other medical conditions. The aim of this study was to test the psychometric properties of the Arabic version of the QPE.

METHODS

We recruited 50 patients with psychotic disorders from the Hamad Medical Hospital in Doha, Qatar. Patients underwent assessment over three sessions with trained interviewees using the Arabic versions of QPE, Positive and Negative Syndrome Scale (PANSS), Beck Depression Inventory (BDI), and the Global Assessment of Functioning Scale (GAF). Patients were also reassessed using the QPE and GAF after 14-days from the initial assessment in order to test for the stability of the scale. In this respect, this is the first study that assesses the test-retest reliability of the QPE. The psychometric properties including convergent validity, stability, and internal consistency met the benchmarked criteria.

RESULTS

Results confirmed that the Arabic version of QPE accurately measured the experiences of patients that were also reported using the PANSS, an internationally accepted, well-established scale for measuring psychotic symptom severity.

CONCLUSION

We propose the use of the QPE to describe the phenomenology of PEs across modalities in Arabic speaking communities.

Incidence, risk and protective factors for suicide mortality among patients with major depressive disorder

AIM

Patients with major depression have greater suicide mortality, but there is no data on the standardised mortality ratio (SMR) and factors for suicide of major depression for Asian countries. This research estimates the SMR and the risk and protective factors for suicide mortality in patients with major depression in a large-scale Asian cohort.

METHODS

Patients with major depression (N = 1978) admitted to a psychiatric hospital in Taiwan between 1985 and 2008 were enrolled as the study cohort. When the cohort was linked to the national mortality database, 415 deceased patients were identified. Of these 415 deaths, 107 were from suicide. Nested case-control with risk sampling was used, where each case was matched with two controls. Clinical information was collected through a standardised chart review process. The SMR for suicide mortality was estimated, and a conditional logistic regression analysis was performed to determine risk and protective factors for suicide.

RESULTS

Patients with major depression had high all-cause and suicide mortality, with SMRs of 3.9 and 35.4, respectively. Agitation (adjusted risk ratio [aRR] = 2.85, P = 0.058), restlessness (aRR = 15.05, P = 0.045) and previous suicide attempts (aRR = 4.48, P = 0.004) were identified as risk factors for suicide mortality. By contrast, those with employment (aRR = 0.15, P = 0.003) or loss of interest (aRR = 0.32, P = 0.04) had lower risk.

CONCLUSIONS

Patients with depression exhibited higher suicide mortality. Clinical staff should pay close attention to risk and protective factors to reduce suicide risk.

Psychotic depression and deaths due to suicide

BACKGROUND

The purpose of this study was to establish the risk of suicide associated with incident psychotic depression (PD) compared to incident non-psychotic severe depression (NPD).

METHODS

This cohort study used routine data from nationwide health registers in Finland. Eligible participants were aged 18-59 years at the index diagnosis. Causes of death were defined by the International Classification of Diseases, 10th revision codes. The follow-up time was up to five years. Adjusted Cox regression models were used to analyse risk of death by method of suicide.

RESULTS

We included 17,331 individuals with incident PD and 85,989 individuals with incident NPD. Most of the deaths due to suicides occurred within the first two years after the index diagnosis. Compared to NPD, PD was associated with an overall two-fold increased risk of suicide (adjusted hazard ratio, (aHR) 2.19, 95 % confidence interval (CI) 1.95, 2.46), after adjusting for psychiatric comorbidities. In PD, the highest relative risks were for impact-related suicides (aHR 3.03, 95%CI 2.23, 4.13) and for suffocation-related suicides (aHR 2.72, 95%CI 2.23, 3.30), whereas the lowest relative risk was for intentional poisonings (aHR 1.66, 95%CI 1.37, 2.02).

LIMITATIONS

Information on all potential confounders is not available in studies using routine data.

CONCLUSIONS

Psychotic symptoms doubled the risk of suicides over and above of the risk that was associated with severe depression, after controlling for comorbid psychiatric disorders. The severity of suicidal ideation may be higher in PD than in NPD, which then leads to more lethal methods of self-harm.

Mortality in psychotic depression: 18-year follow-up study

BACKGROUND

Evidence on the role of co-occurring psychiatric disorders in mortality associated with psychotic depression is limited.

AIMS

To estimate the risk of cause-specific mortality in psychotic depression compared with severe non-psychotic depression while controlling for comorbid psychiatric disorders.

METHOD

This cohort study used routine data from nationwide health registers in Finland. Eligible participants had their first diagnosis for psychotic depression or for severe non-psychotic depression between the years 2000 and 2018, had no pre-existing diagnoses for schizophrenia spectrum disorders or bipolar disorder, and were aged 18-65 years at the index diagnosis. Causes of death were defined by ICD-10 codes. The follow-up time was up to 18 years.

RESULTS

We included 19 064 individuals with incident psychotic depression and 90 877 individuals with incident non-psychotic depression. Half (1199/2188) of the deaths in those with psychotic depression occurred within 5 years from the index diagnosis and the highest relative risk was during the first year after the diagnosis. Compared with individuals with non-psychotic depression, those with psychotic depression had a higher risk of all-cause mortality (adjusted hazard ratio, aHR = 1.59, 95% CI 1.48-1.70), suicides (aHR = 2.36, 95% CI 2.11-2.64) and fatal accidents (aHR 1.63, 95% CI 1.26-2.10) during the subsequent 5-year period after the index diagnosis.

CONCLUSIONS

Psychotic symptoms markedly added to the mortality risk associated with severe depression after controlling for psychiatric comorbidity. Prompt treatment and enhanced monitoring for psychotic symptoms is warranted in all patients with severe depression to prevent deaths because of suicides and other external causes.

Cross-continental collaboration for understanding postpartum major depression with psychotic features

Purpose

Assess postpartum depression and psychotic symptoms from three continents.

Methods

Compare numbers of women with depression and psychotic symptoms, mania with or without psychotic features, or transient non-affective psychosis and medication choice.

Results

The prevalence of postpartum depression and psychosis and treatment choice differed at each site.

Conclusions

Best treatment for postpartum depression with psychotic features has not been established yet. Cross-continental collaboration with similar assessments holds promise to develop best practices for these high risk mother-infant dyads.

Relationship among psychotic features, benzodiazepine receptor agonists, and rehospitalization in patients with electroconvulsive therapy-responsive major depressive disorder: A retrospective 2-year observational study

AIM

It is controversial whether psychotic features are a risk factor for relapse in patients with electroconvulsive therapy-responsive major depressive disorder. A recent study reported that benzodiazepine receptor agonists reduce relapse of psychotic depression. As long-term use of these agonists may induce dependence, further research is required. We examined whether psychotic features are associated with rehospitalization in electroconvulsive therapy-responsive major depressive disorder patients. We also investigated whether taking benzodiazepine receptor agonists at the end of electro-convulsive therapy was associated with rehospitalization among patients with psychotic depression.

METHODS

This study included 47 hospitalized patients (22 with psychotic depression, 25 with non-psychotic depression) who had responded to electroconvulsive therapy. Rehospitalization for major depressive episodes within two years from the last session was investigated.

RESULTS

Twenty-three subjects (49%) were rehospitalized during the two-year follow-up. Kaplan-Meier analysis revealed no difference in rehospitalization between patients with psychotic and non-psychotic depression (Log-rank P = 0.87). Among the 22 responders to electroconvulsive therapy with psychotic depression, there was no difference in benzodiazepine receptor agonist use at the end of electroconvulsive therapy between the rehospitalization and non-rehospitalization groups.

CONCLUSION

Our exploratory study found no difference in the benzodiazepine receptor agonists use at the end of electroconvulsive therapy between rehospitalization and non-rehospitalization groups in patients with electroconvulsive therapy-responsive psychotic depression. Thus, the relapse-preventing effect of these agonists in psychotic depression should be investigated in future randomized controlled trials. Further research is also needed to determine whether psychotic features are associated with rehospitalization in these patients.

Prevalence, clinical features and prescription patterns of psychotropic medications for patients with psychotic depression in China

OBJECTIVE

To investigate the prevalence of psychotic depression and the differences in sociodemographic and clinical characteristics and prescription patterns of psychotropic medications between patients with psychotic depression (PD) and patients with nonpsychotic depression (NPD) in China.

METHODS

We conducted a cross-sectional study in 13 major psychiatric hospitals or the psychiatric units of general hospitals in China from September 1, 2010, to February 28, 2011. PD was defined according to the psychotic disorder section of the Mini International Neuropsychiatric Interview (MINI). The sociodemographic and clinical characteristics and the prescription patterns of psychotropic medications were compared between the PD and NPD groups. Multivariate logistic regression analysis was used to investigate factors associated with an increased likelihood of PD.

RESULTS

Among 1172 MDD patients, the prevalence of psychotic features was 9.2% in the present study. The logistic regression analysis indicated that unmarried (OR = 2.08, p < 0.001), frequent depressive episodes (OR = 2.10, p = 0.020), depressive episodes with suicidal ideation and attempts (OR = 1.91, p = 0.004), and patients who were prescribed any antipsychotics (OR = 2.94, p < 0.001) were associated with psychotic features in patients with MDD.

LIMITATIONS

Cross-sectional design, retrospective recall of some data CONCLUSION: The prevalence of PD is high in China, and there were some differences in demographic and clinical characteristics between patients with PD and patients with NPD. Clinicians should regularly assess psychotic symptoms and consider intensive treatment and close monitoring when treating subjects with PD.

Clinical Approaches to Late-Onset Psychosis

Psychosis can include schizophrenia, mood disorders with psychotic features, delusional disorder, active delirium, and neurodegenerative disorders accompanied by various psychotic symptoms. Late-onset psychosis requires careful intervention due to the greater associated risks of secondary psychosis; higher morbidity and mortality rates than early-onset psychosis; and complicated treatment considerations due to the higher incidence of adverse effects, even with the black box warning against antipsychotics. Pharmacological treatment, including antipsychotics, should be carefully initiated with the lowest dosage for short-term efficacy and monitoring of adverse side effects. Further research involving larger samples, more trials with different countries working in consortia, and unified operational definitions for diagnosis will help elaborate the clinical characteristics of late-onset psychosis and lead to the development of treatment approaches.

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.

Relapse following bitemporal and high-dose right unilateral electroconvulsive therapy for major depression

OBJECTIVE

Electroconvulsive therapy (ECT) is an effective acute treatment for severe and/or medication-resistant depression but maintaining remission following completion of a course remains a clinical challenge.

METHODS

EFFECT-Dep Trial (ISRCTN23577151) participants with a DSM-IV major depressive episode who met remission criteria after a randomly assigned course of twice-weekly brief-pulse bitemporal (1.5 × seizure threshold) or high-dose (6 × seizure threshold) right unilateral ECT were monitored for relapse for 12 months. In line with the pragmatic trial design, all patients received treatment-as-usual individualised pharmacotherapy during and after ECT; no remitter received continuation ECT.

RESULTS

Of 61 remitters, 24 (39.3%) relapsed, one (1.6%) withdrew from the study while in remission and the remaining 36 (59.0%) stayed well for a year. Most relapses occurred within the first six months, resulting in a cumulative six-month relapse rate of 31.1%. In a multivariable Cox proportional hazards regression model, older age (p = 0.039) and psychotic features at pre-ECT baseline (p = 0.037) were associated with a more favourable long-term prognosis while a greater number of previous depressive episodes (p = 0.028) and bipolar II (but not bipolar I) diagnosis (p = 0.030) were associated with a worse long-term outcome. Electrode placement and medication resistance prior to ECT had no effect on relapse. Adjusting for covariates, fewer patients treated with lithium relapsed in the overall group (p = 0.008) and in the unipolar depression subgroup (p = 0.027).

CONCLUSION

Long-term outcome following high-dose right unilateral ECT does not differ from bitemporal ECT. Prognosis is particularly favourable in older adults, psychotic depression and patients maintained on lithium.

Suicidal ideation during COVID-19 lockdown in Greece: Prevalence in the community, risk and protective factors

The aim of this study was to investigate the prevalence of suicidal ideation in the community as well as the risk and protective factors of suicidal ideation during restriction measures in Greece, after the outbreak of the COVID-19 pandemic. Α web-based anonymous survey was conducted during the first lockdown period. Participants completed the Generalized Anxiety Disorder scale (GAD-2), the Patient Health Questionnaire (PHQ-2), the Systemic Clinical Outcome and Routine Evaluation (SCORE-15), the Connor-Davidson Resilience Scale (CD-RISK-2), and a self-report questionnaire for COVID-19 pandemic-related data. From a total of 5,116 adults included in the study, 5.20% reported suicidal thoughts, 14.17% were potential clinical cases of anxiety, and 26.51% of depression. Participants presented significantly higher suicidal ideation rates during the last two weeks of the lockdown compared to its previous two weeks. Unmarried or divorced marital status, mental health history, poor perceived quality of physical health, impaired family functioning, anxiety and depression symptoms were independently associated with higher odds of suicidal ideation, whereas higher resilience, positive feelings with regard to the lockdown measures, relationship with friends, and faith in a Supreme Being were associated with lower suicidal ideation odds. According to the findings, suicidal ideation prevalence might be considered elevated and its increase during the lockdown period alarming. The risk and protective factors identified in the study offer valuable information for the development of preventive strategies against suicidal ideation, especially in times of crisis.

Recent Updates on Electro-Convulsive Therapy in Patients with Depression

OBJECTIVE

Electro-convulsive therapy (ECT) has been established as a treatment modality for patients with treatment-resistant depression and with some specific subtypes of depression. This narrative review intends to provide psychiatrists with the latest findings on the use of ECT in depression, devided into total eight sub-topics.

METHODS

We searched PubMed for English-language articles using combined keywords and tried to analyze journals published from 1995-2020.

RESULTS

Pharmacotherapy such as antidepressants or maintenance ECT is more effective than a placebo as prevention of recurrence after ECT. The use of ECT in treatment-resistant depression, depressed patients with suicidal risks, elderly depression, bipolar depression, psychotic depression, and depression during pregnancy or postpartum have therapeutic benefits. As possible mechanisms of ECT, the role of neurotransmitters such as serotonin, dopamine, gamma-aminobutyric acid (GABA), and other findings in the field of neurophysiology, neuro-immunology, and neurogenesis are also supported.

CONCLUSION

ECT is evolving toward reducing cognitive side effects and maximizing therapeutic effects. If robust evidence for ECT through randomized controlled studies are more established and the mechanism of ECT gets further clarified, the scope of its use in the treatment of depression will be more expanded in the future.

Effect of adjunctive pimavanserin on suicidal ideation in patients with major depression: Analysis of the CLARITY study

BACKGROUND

Up to 15% of patients with major depressive disorder (MDD) attempt suicide and up to 2% complete suicide. This was a post-hoc analysis aimed to evaluate the risk of suicide ideation and behavior associated with adjunctive pimavanserin treatment in adults with MDD.

METHODS

CLARITY was a randomized, double-blind, placebo-controlled study in patients with MDD and an inadequate response to a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI). For this post-hoc analysis, the primary endpoint was mean change from baseline for HAMD item 3 (suicide). The incidence of suicidal ideation or behavior was also assessed from the Columbia-Suicide Severity Rating Scale (C-SSRS) and reports of adverse events.

RESULTS

During Stage 1, LS mean change for HAMD Item 3 was reduced from baseline at each week with pimavanserin with a significant difference between pimavanserin and placebo at Week 3 (p=0.012, effect size: 0.431). At any post-baseline assessment, suicidal ideation on the C-SSRS was reported in 28 (18.1%) of patients with placebo and 9 (17.3%) with pimavanserin during Stage 1 and in 7 (20.7%) with placebo and 4 (13.8%) with pimavanserin during Stage 2. No events of suicidal behavior were observed with either placebo or pimavanserin.

LIMITATIONS

The post hoc nature, exclusion of patients with any history of suicide from the primary study, and the small number of patients who demonstrated evidence of suicidal ideation.

CONCLUSIONS

Adjunctive pimavanserin was not associated with an increase in suicidal ideation in patients with MDD. Further study is needed to verify these results.

Psychotic depression in hospitalized patients: Longitudinal outcomes of psychotic vs. nonpsychotic depression among inpatients

Even though psychotic depression is related to worse outcomes than nonpsychotic depression, there is increasing evidence that this greater severity is not solely explained by the depressive symptoms. We evaluated the socio-demographic and clinical characteristics, as well as the differences in clinical outcomes of psychiatric hospitalization between psychotic and non-psychotic depression. Two-hundred-eighty-eight depressive inpatients were assessed within 72 h after hospitalization and 24 h before discharge. We compared scores of Hamilton Depression Rating Scale 17-items (HDRS-17), Clinical Global Impression (CGI), Brief Psychiatric Rating Scale (BPRS), and Global Assessment of Functioning (GAF) between psychotic and nonpsychotic patients. Instruments were compared both cross-sectionally - on admission and discharge - and longitudinally. Longitudinal outcomes were corrected for potential confounders (sex, age, age at disease onset, years of study, previous history of mania/hypomania, electroconvulsive therapy in current hospitalization, history of attempted suicide, number of suicide attempts, and previous hospitalizations). One-hundred-thirty-one depressive inpatients (45.4%) presented psychotic features. Both groups showed similar HDRS-17 scores at admission and discharge. However, psychotic patients had worse scores on BPRS, CGI, and GAF at both timepoints. Both groups had similar improvement on HDRS-17 (P = 0.75), CGI (P = 0.5), and GAF (P = 0.84), but psychotic patients had greater improvement on BPRS (P < 0.001). Psychotic inpatients showed worse clinical and functional parameters. Nonetheless, the groups did not differ in depressive symptom severity. These findings reinforce the hypothesis that depressive episode with psychotic features is a more severe form of the disease irrespective of intensity of affective symptomatology.

Relaxation techniques for depressive disorders in adults: a systematic review and meta-analysis of randomised controlled trials

Objectives: The aim of this study was to identify, evaluate, and synthesise existing randomised controlled trials (RCTs) that examined the effect of relaxation techniques in the treatment of patients with depressive disorders.Methods: A systematic review of the literature was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines.Results: Nine studies were finally included in this meta-analysis. It was found that relaxation techniques might effectively reduce depressive symptoms among adults with depression (standardised mean difference (SMD) -0.42, 95% CI -0.72 to -0.11, p  =  0.008).Conclusions: Relaxation techniques are cost-effective, safe, and low-risk techniques that can be easily taught and used. Consequently, they have several benefits if practised regularly daily for more than an 8-week period.KEY POINTS/HIGHLIGHTSThe implication of this study for practice is that these relaxation techniques, cost-effective, safe, and low-risk techniques that can be easily taught and used.Consequently, practitioners will access benefits if practised regularly daily for more than an 8-week period.The relaxation technique is not complex, does not need any special device or place, does not need any change in lifestyle and is easily learned.

Depression with and without a history of psychotic symptoms in the general population: sociodemographic and clinical characteristics

BACKGROUND

The aim of this study was to find the sociodemographic and clinical characteristics of major depressive episode (MDE) with (MDE-HPS+) and without a history of psychotic symptoms (MDE-HPS) in the general population.

METHODS

The Mental Health in the General Population survey interviewed 38,694 individuals in France by using the MINI. The prevalence and sociodemographic and clinical correlates of MDE-HPS+ were assessed.

RESULTS

Of the sample, 11.2% were diagnosed with current MDE and among them, 39.3% presented a history of at least one psychotic symptom (hallucination or delusion). Patients with MDE-HPS+ were younger with more severe social impairment than those with MDE-HPS-. We also found a higher proportion of three generations of migrants in the MDE-HPS+ group. Comorbid psychiatric disorders such as a history of a manic episode, alcohol use disorder, social anxiety, generalized anxiety disorder, and a personal history of a suicide attempt were more frequent in patients with MDE-HPS+ than in those with MDE-HPS-. Finally, we found a specific gradient of severity for psychiatric comorbid disorders depending on the number of psychotic symptoms lifetime in MDE.

LIMITATIONS

The study also has an observational cross-sectional design that does not permit causal inferences, and it is difficult to eliminate recall bias and reporting errors.

CONCLUSION

In the general population, patients with MDE-HPS+, when compared to MDE-HPS-, presented with a more severe clinical profile, with increased rates of psychiatric comorbidities, particularly a history of bipolar disorder and a history of a suicide attempt.

Comorbid Anxiety and Suicidal Behaviors in American Adolescents With Major Depression

Objective The aim of this study was to evaluate the odds of association between suicidal behaviors and comorbid anxiety disorders in adolescents with major depressive disorder (MDD). Methods We included 122,020 adolescent inpatients with MDD from the Nationwide Inpatient Sample (NIS) and further grouped them by co-diagnosis of anxiety disorders. Logistic regression analysis was used to evaluate the odds ratio (OR) of suicidal behaviors due to comorbid anxiety disorders. Results Out of total MDD inpatients, 45.8% had comorbid anxiety disorders. Around 53.5% MDD inpatients with anxiety disorders had suicidal behaviors, which were significantly higher than seen in 52.6% non-anxiety cohort (P = 0.002). Comorbid anxiety disorders had a minimally positive association with suicidal behaviors and were not statistically significant (OR: 1.01; P = 0.710) after controlling the logistic regression analysis for demographic confounders and psychiatric comorbidities. MDD inpatients with comorbid psychotic disorders were positively associated (OR: 1.16; P = 0.007) with suicidal behaviors. Conclusions MDD with comorbid anxiety had a statistically non-significant association with suicidal behaviors in adolescents. Depression has a direct and independent effect on adolescent suicidal behaviors, whereas anxiety has a direct effect only on perpetuating depression. Early diagnosis and management of comorbid anxiety and psychosis with MDD reduce functional impairment and suicide risk in at-risk populations.

Risk for Suicidal Behavior Among Psoriasis Patients: A Nationwide Cohort Study

BACKGROUND

The link between psoriasis and suicidality remains elusive and understudied.

OBJECTIVE

The aim was to assess the risk of suicidal behavior in psoriasis patients.

METHODS

We used Taiwan's National Health Insurance Research Database to conduct a nationwide retrospective cohort study to examine the risk for suicidal behavior among psoriasis patients. We performed subgroup analyses based on the severity of psoriasis and psoriatic arthritis.

RESULTS

We included 169,909 psoriasis patients (including 13,959 with concomitant psoriatic arthritis and 155,950 with psoriasis alone) and 169,909 matched nonpsoriasis controls. Suicidal behavior occurred in 104 and 89 subjects in the psoriasis group and nonpsoriasis controls, respectively; we found no significantly increased risk for suicidal behavior among psoriasis patients when compared to nonpsoriasis controls [adjusted hazard ratio (HR) 1.17, 95% confidence interval (CI) 0.88‒1.55]. The subgroup analysis showed no significantly increased risk for suicidal behavior in both the severe psoriasis group (adjusted HR 0.92, 95% CI 0.51-1.64) and the mild psoriasis group (adjusted HR 1.26, 95% CI 0.91‒1.75) when compared to nonpsoriasis controls. Also, we found no significant increased risk for suicidal behavior in the group of psoriasis patients who also had psoriatic arthritis (adjusted HR 2.00, 95% CI 0.68‒5.85) and in the group of patients with psoriasis alone (adjusted HR 1.12, 95% CI 0.83‒1.50) when compared to nonpsoriasis controls.

CONCLUSION

In a Taiwanese setting, no link between psoriasis or psoriatic arthritis and suicidal behavior was detected.

Prevalence and related factors of suicide attempts in first-episode and untreated Chinese Han outpatients with psychotic major depression

BACKGROUND

Major depressive depression (MDD) is often accompanied by suicidal behavior. Increasing evidence shows that MDD patients display psychotic symptoms. However, the relationship between psychotic symptoms and suicide attempt in MDD has not been reported. Therefore, this study was to identify the prevalence and associated factors of suicide attempts in first-episode and untreated Chinese Han outpatients comorbid with psychotic major depression (PMD).

METHODS

1718 first-episode and untreated MDD outpatients were assessed with Positive Symptom Scale of Positive and Negative Syndrome Scale (PANSS), the 17-item Hamilton Depression Scale, Hamilton Anxiety Scale, and clinical global impression of severity scale (CGI-S). Some glycolipid metabolism and thyroid hormone parameters were measured.

RESULTS

In MDD patients, the percentage of PMD was 10.0%. The incidence of attempted suicide in PMD patients was 51.5%, which was more than 3 times higher than that in non-PMD patients (16.7%). In PMD patients, compared to non-attempters, suicide attempters were older, had a longer course of disease, scored higher on all scales, as well as had higher levels of thyroid stimulating hormone (TSH), thyroid peroxidases antibody, anti-thyroglobulin and blood glucose. PANSS positive symptom, CGI, diastolic blood pressure and TSH were independently associated with suicide attempts of PMD.

CONCLUSIONS

PMD patients have a higher prevalence of suicide attempt than non-PMD patients. Some demographic and clinical parameters are relevant factors for suicide attempt in PMD patients.

Preventing Suicide among Psychiatric Inpatients with Psychotic Depression

To investigate which factors individuals with a psychotic depression experience as preventive of suicide while beeing hospitalized. Semi-structured qualitative interviews with nine inpatients, all hospitalized for a unipolar or bipolar depressive episode with psychosis, were conducted at time of discharge. For analysis we used systematic text condensation. Main outcomes were accounts of participants' experiences of suicide prevention measures and treatment, and how these affected suicidal ideation, plans, and attempts. Participants experienced (1) suicide attempts being physically interrupted or prevented; (2) receiving medical treatment to alleviate unbearable suffering; (3) finding refuge behind locked doors; (4) receiving guidance to redefine their identity and situation. They reported being protected from suicidal impulses and imagined persecutors in a secure environment with staff present. They described their autonomy as compromised by intense suffering and chaos. They retrospectively appreciated staff interventions, if these were performed compassionately and with empathy. Participants described that suicidal thoughts and actions were triggered by terrifying psychotic experiences, anxiety and sleeplessness, and felt that medication - and in one instance electroconvulsive therapy- alleviated suffering. At time of discharge, participants reported no psychotically motivated suicidal thoughts. They described a new, insightful self-view and acknowledged having been severely mentally ill. To prevent impulsive suicidal behavior, findings highlight the need for both security measures and a treatment approach focusing on modifying psychotic experiences and intense anxiety. Gaining anxious and paranoid patients' trust is essential to build motivation for medical treatment. Patients emphasize that having time to talk is crucial to this process.

Brain changes in depression

The present review addresses major depressive disorder (MDD) and the implications of antidepressant treatment in the field of brain neuroplasticity, an effect initially considered adjacent but currently passed as central in the process of remission of MDD. Both in experimental animal studies and in human studies in subjects with mood disorders, neuroplasticity is considered the fundamental mechanism of neural defense against stress. Stress is the mediator between neurofunctional, neuroendocrine, neurobiological and neuroimmune disorders and depressive pathology of various intensities. Neurons have a high potential to adapt to the influences of internal and external factors. We are talking about neuroplasticity at different levels: structural neuroplasticity involving adult neurogenesis (such as plastic changes, dendritic reconstruction, when the morphology of the spine is affected); synaptic functional neuroplasticity and molecular and cellular mechanisms involved. These two major dimensions explain the pathophysiology of depression, as well as the convergence of the mechanisms involved in stress, major depressive decompensations, and the concept of neuroplasticity as the present target for new effective and potent antidepressant treatments.

Antidepressant Potential of Cinnamic Acids: Mechanisms of Action and Perspectives in Drug Development

Depression is a health problem that compromises the quality of life of the world's population. It has different levels of severity and a symptomatic profile that affects social life and performance in work activities, as well as a high number of deaths in certain age groups. In the search for new therapeutic options for the treatment of this behavioral disorder, the present review describes studies on antidepressant activity of cinnamic acids, which are natural products found in medicinal plants and foods. The description of the animal models used and the mechanisms of action of these compounds are discussed.

Effect of Continuing Olanzapine vs Placebo on Relapse Among Patients With Psychotic Depression in Remission: The STOP-PD II Randomized Clinical Trial

Importance

Psychotic depression is a severely disabling and potentially lethal disorder. Little is known about the efficacy and tolerability of continuing antipsychotic medication for patients with psychotic depression in remission.

Objective

To determine the clinical effects of continuing antipsychotic medication once an episode of psychotic depression has responded to combination treatment with an antidepressant and antipsychotic agent.

Design, Setting, and Participants

Thirty-six week randomized clinical trial conducted at 4 academic medical centers. Patients aged 18 years or older had an episode of psychotic depression acutely treated with sertraline plus olanzapine for up to 12 weeks and met criteria for remission of psychosis and remission or near-remission of depressive symptoms for 8 weeks before entering the clinical trial. The study was conducted from November 2011 to June 2017, and the final date of follow-up was June 13, 2017.

Interventions

Participants were randomized either to continue olanzapine (n = 64) or switch from olanzapine to placebo (n = 62). All participants continued sertraline.

Main Outcomes and Measures

The primary outcome was risk of relapse. Main secondary outcomes were change in weight, waist circumference, lipids, serum glucose, and hemoglobin A1c (HbA1c).

Results

Among 126 participants who were randomized (mean [SD] age, 55.3 years [14.9 years]; 78 women [61.9%]), 114 (90.5%) completed the trial. At the time of randomization, the median dosage of sertraline was 150 mg/d (interquartile range [IQR], 150-200 mg/d) and the median dosage of olanzapine was 15 mg/d (IQR, 10-20 mg/d). Thirteen participants (20.3%) randomized to olanzapine and 34 (54.8%) to placebo experienced a relapse (hazard ratio, 0.25; 95% CI, 0.13 to 0.48; P < .001). The effect of olanzapine on the daily rate of anthropometric and metabolic measures significantly differed from placebo for weight (0.13 lb; 95% CI, 0.11 to 0.15), waist circumference (0.009 inches; 95% CI, 0.004 to 0.014), and total cholesterol (0.29 mg/dL; 95% CI, 0.13 to 0.45) but was not significantly different for low-density lipoprotein cholesterol (0.04 mg/dL; 95% CI, -0.01 to 0.10), high-density lipoprotein cholesterol (-0.01 mg/dL; 95% CI, -0.03 to 0.01), triglyceride (-0.153 mg/dL; 95% CI, -0.306 to 0.004), glucose (-0.02 mg/dL; 95% CI, -0.12 to 0.08), or HbA1c levels (-0.0002 mg/dL; 95% CI, -0.0021 to 0.0016).

Conclusions and Relevance

Among patients with psychotic depression in remission, continuing sertraline plus olanzapine compared with sertraline plus placebo reduced the risk of relapse over 36 weeks. This benefit needs to be balanced against potential adverse effects of olanzapine, including weight gain.

Trial Registration

ClinicalTrials.gov Identifier: NCT01427608.

Guilt Delusional Beliefs Increase the Risk of Suicidal Attempt in Elderly Unipolar Psychotic Depressives

The aim of this study was to investigate the differential effect of various delusion categories, namely, guilt, paranoid, impending disaster, and somatic on suicidal attempts in elderly patients experiencing unipolar psychotic major depression (PMD), because the evidence on this is scarce. The sample consisted of 65 consecutively admitted patients 60 years or older, experiencing PMD, and assessed by means of Structured Clinical Interview for DSM-4 (Patient Edition), Hamilton Depression Rating Scale, Mini-Mental Status Examination (MMSE), and by a physical impairment rating scale. Patients with guilt delusional beliefs had 5.31 times higher odds (95% confidence interval, 1.37-25.40) of a suicidal attempt than the patients without guilt delusional beliefs, controlling for sex, age, prior history of suicide attempt, MMSE, and hallucinations. In addition, 17 PMD patients with lifetime suicidal attempt compared with 48 PMD patients without lifetime suicidal attempt presented only higher age of disorder onset (p = 0.008). Of the four categories of delusions assessed, only guilt delusions were associated with an increased risk for suicidal attempt.