Psychotic Depression: An Evidenced Based Clinical Update

~\ This is an article based on an extensive literature review dealing with psychotic major depression, which is a relatively common subtype of depression that is easily misdiagnosed and therefore has the potential to be inadequately treated. The article is written for the target audience of primary care clinicians and outpatient psychiatric clinicians. The aspects of psychotic major depression that will be discussed are: clinical symptoms and diagnosis, prevalence and social characteristics, clinical course, familial history and genetic characteristics, neuropsychological aspects, biological aspects, and treatment. Suggestions for clinical practice are included. 3 Psychotic Depression: An Psychotic Depression: An Evidenced Based Clinical Update Introduction Psychotic depression is a relatively common subtype of Major Depression. It is a severe form of mood disorder characterized by delusions, hallucinations, psychomotor disturbances, increased feelings of guilt, and suicidal ideation. It is estimated that this form of depression affects 0.4% of the population (Keller et aI., 2006). According to the DSM-IV-TR (American Psychiatric Association[APA], 2000), the lifetime risk for Non Psychotic Major Depression in community samples varies from 10% to 25% for females and from 5% to 12% for men Psychotic depression is easily mistaken for non-psychotic major depression and therefore can potentially be treated inadequately. Although the DSM-IV-TR (APA, 2000) criteria suggest that the essential difference between psychotic major depression (PMD) and non-psychotic major depression (NPMD) is the presence of delusions and/or hallucinations, many researchers have observed that the two syndromes are very distinct with different symptoms, clinical courses, familial patterns, cognitive changes, and biological features. The purpose of this article is to review the current knowledge base regarding the identification, clinical profile, and treatment of PMD in order to better inform APRN practice. Literature Review A review of the current literature on PMD revealed several focal areas of interest on the topic: clinical symptoms and diagnosis of psychotic depression, prevalence and social characteristics, clinical course, familial history/genetic characteristics, neuropsychological aspects, biological aspects, and the treatment of psychotic depression. These will be discussed and summarized in this article. 4 Psychotic Depression: An Clinical Symptoms and Diagnosis of PMD The DSM-IV-TR (APA 2000) does not have any specific diagnostic criteria for PMD (see Appendix I for DSM-IV-TR criteria for a major depressive episode). In a study by Keller et aI. , (2006), the authors used the Brief Psychiatric Rating Scale (BPRS) (see Appendix 4) during patient interviews to differentiate between PMD and NPMD. The BPRS is an 18 item scale used to measure the severity of psychiatric symptomatology and has been used for decades as an outcome measure in treatment studies of various types of psychosis (Sadock & Sadock, 2007). The aim of the study was to assess whether individual or clusters of psychiatric symptoms could differentiate between PMD and NPMD. The authors studied 129 patients with major depressive disorder and determined that patients with psychotic depression were adequately differentiated by the Unusual Thought Content item of the BPRS. In a later article in 2007, Keller, Schatzberg, and Maj reported that any elevation, even a very small one, on the Positive Symptom Subscale of (" the BPRS (conceptual disorganization, suspiciousness, hallucinations, and unusual thought content) was even better at differentiating PMD from NPMD. Sensitivity and specificity for this scale were 84% and 99%, respectively. Ohayon and Schatzberg reported in 2002 that feelings of worthlessness or excessive guilt are a good indicator of psychotic symptoms in depressed patients. Meyers et aI. , (2006) developed a scale to quantify and measure delusions in patients with psychotic depression. According to Meyers, " . the presence of delusions or hallucinations are critical to the diagnosis of major depression with psychotic features" (pg. 1336). Meyers goes on to state that hallucinations without accompanying delusions are rare in PMD, which highlights the importance of assessing and quantifying delusions in patients with PMD. The scale that the authors created is called the Delusion Assessment Scale and it is comprised of 15 items (see 5 Psychotic Depression: An Appendix 2). The Delusion Assessment Scale was administered to the 92 subjects enrolled in a study of pharmacotherapy for patients with PMD and the scores correlated significantly with BPRS Positive Symptom Subscale scores. Similarly, Schatzberg and Rothschild (1992) stated that the hallmark feature separating PMD from NPMD is the occurrence of delusions and hallucinations in PMD. The delusions typically fall into the categories of guilt, paranoia, or somatization. Delusions are viewed as mood congruent if they reflect depressed mood via underlying nihilistic, guilty, or overly self­ deprecating beliefs. Hallucinations are divided into auditory, visual and somatic subtypes. According to the authors, although psychotic depressions are often severe in nature, severity alone is not sufficient to differentiate PMD from NPMD. The authors do report that patients with PMD typically have greater psychomotor disturbance, feelings of guilt, and cognitive disturbance. In addition, patients with PMD tend to express more hopelessness, hypochondriasis, anxiety, and insomnia (early and middle); however these symptoms are less prominent and consistent when compared to psychomotor disturbance and guilt feelings. The authors also report that patients with PMD exhibit greater morbidity, including more frequent suicide attempts. Rothschild (2003) also discusses the diagnosis of PMD. The author reports that the diagnosis of PMD cannot be made unless the clinician can detect the presence of delusions or hallucinations in the context of a major depressive episode (see Appendix 1). Rothschild also states that the psychotic symptoms can be present only in the context of the major depressive episode. Because the detection of delusions and hallucinations in depressed patients can be difficult, other characteristics can help detect PMD. Among those characteristics are, according to Rothschild, severe psychomotor disturbance, pronounced paranoid symptoms, cognitive 6 Psychotic Depression: An impairment, hypochondriasis, anxiety, insomnia (early and middle), and constipation. This author observed that patients with PMD do not exhibit a diurnal variation in mood when compared with severely depressed, non psychotic patients, meaning that patients with NPMD typically experience more severely depressed mood in the morning that improves as the day progresses, and patients with PMD tend to experience a severely depressed mood all day with little to no improvement as the day progresses. In summary, PMD can be a difficult disorder to accurately quantify and diagnose. Excessive feelings or worthlessness and or guilt, as well as delusional thought content in general, can help the clinician to recognize PMD. Because PMD could be missed during the initial patient evaluation if the interviewer does not adequately question the patient about the presence of delusional thinking, the BPRS is helpful in establishing the diagnosis. In addition, the features of cognitive impairment, hypochondriasis, psychomotor disturbance, insomnia, and the absence of diurnal mood variation can help identify PMD. The following section will discuss the prevalence and social characteristics commonly observed in patients with PMD. Prevalence and Social Characteristics Ohayon and Schatzberg (2002) examined the prevalence of depressive episodes with psychotic features in the general population. The authors studied phone interview transcripts of 18,980 subjects residing in the UK, Germany, Italy, Portugal, and Spain. The study subjects were randomly selected and did not have to be engaged in any psychiatric treatment to be included in the study The phone interviews were performed by trained lay interviewers who were prompted by the SLEEP EVAL computer program to ask the participants questions dealing with symptoms of depression as well as symptoms of psychosis. The authors concluded at the 7 Psychotic Depression: An end of the study that major depressive episodes with psychotic features are relatively frequent in the population, affecting approximately 0.4% ofthe population. In an article written by Thakur, Hays, Ranga and Krishnan (1999), the authors examined the prevalence, demographic and social characteristics of PMD. The authors concluded that PMD is found in 25% of consecutively admitted depressed patients. This rate was also reported in Coryell, Pfohl, and Zimmerman, (1984), Wheeler, Mortimer, and Tyson, (2000), and Wijkstra, Lijmer, Balk, Geddes, and Nolan, (2006). Consecutive admissions may indicate more severe depression. In this study (Thakur et al., 1999),674 patients with MOD were screened for delusions and hallucinations, in addition to age, gender, family history of suicide, lifetime history of bipolar diagnosis, psychomotor disturbance, guilt feelings, worthless feelings, presence of suicidal ideation, intent, and attempts, age at onset of first episode, vascular risk factors, and perceived social support. Of the 674 patients studied by Thakur, et al., patients with PMD were twice as likely to be younger than 60, 66% more likely to be actively suicidal, and 50% more likely to exhibit psychomotor disturbance. Patients with PMD were 26 times more likely to have a past history of delusions, and because of this, a current episode of delusional depression, or PMD, could reasonably be considered predictive of delusional episodes in the future. Patients with PMD were also 66% more likely to be experiencing guilty feelings and were significantly more likely to be exp