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
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 up date of a review first published in 2005 and last up date d 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 .
A double-blind, fixed blood-level study comparing mirtazapine with imipramine in depressed in-patients
Antidepressant effects of mirtazapine and imipramine were compared in a r and omized , double blind , fixed blood-level study with in- patients in a single centre . Patients with a DSM-III-R diagnosis of major depression and a Hamilton ( 17-item ) score of ≥18 were selected . After a drug-free and a placebowashout period of 7 days in total , 107 patients still fulfilling the HRSD criterion of ≥18 , started on active treatment . The dose was adjusted to a predefined fixed blood level to avoid suboptimal dosing of imipramine . Concomitant psychotropic medication was administered only in a few cases because of intolerable anxiety or intolerable psychotic symptoms . Eight patients dropped out and two were excluded from analyses because of non-compliance ; 97 completed the study . According to the main response criterion ( 50 % or more reduction on the HRSD score ) 11/51 ( 21.6 % ) patients responded on mirtazapine and 23/46 ( 50 % ) on imipramine after 4 weeks ' treatment on the predefined blood level . Such a dramatic difference in efficacy between antidepressants has not often been reported before . The selection of ( severely ill ) in- patients , including those with suicidal or psychotic features , may have significance in this respect . Optimization of treatment with the reference drug imipramine through blood level control , exclusion of non-compliance for both drugs , exclusion of most concomitant medication and a low drop-out rate may also have contributed . It is concluded that imipramine is superior to mirtazapine in the patient population studied
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
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 up date of a review first published in 2005 and last up date d 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 .