Major Depressive Disorder With Psychotic Features Vs Schizoaffective Disorder Latest 2023

psychotic depression
Other names	depressive psychosis
A drawing that tries to capture sadness, loneliness and detachment from reality, as described by patients with psychotic depression
Specialty	Psychiatry
Symptoms	Hallucinations, delusions, anhedonia, psychomotor retardation, sleep problems,
Complications	Suicide, self-mutilationrisk of relapse of psychotic depression
usual start	20-40 years
Duration	Days to weeks, sometimes longer
diagnostic method	clinical interview
Differential diagnosis	schizoaffective disorder, schizophrenia, personality disorders, dissociative disorders
Treatment	medicine, cognitive behavioral therapy
medicine	antidepressants, antipsychotics

psychotic depressionalso known as depressive psychosisit is a major depressive episode which is accompanied by psychotic symptoms. It can occur in the context of bipolar disorder or major depressive disorder. It can be difficult to distinguish from schizoaffective disorder, a diagnosis that requires the presence of psychotic symptoms for at least two weeks with no mood symptoms present. Unipolar psychotic depression requires that psychotic features occur only during episodes of major depression. Diagnosis using the DSM-5 involves meeting criteria for a major depressive episode, along with criteria for “mood congruent or incongruous humor psychotic features” specifier.

Signs and symptoms

Individuals with psychotic depression have the symptoms of a major depressive episode along with one or more psychotic symptoms, including delusions and/or hallucinations. Delusions can be classified as either mood congruent or incongruent, depending on whether or not the nature of the delusions is in line with the individual’s mood state. Common themes of mood-congruent delusions include guilt, persecution, punishment, personal inadequacy, or illness. Half of patients experience more than one type of delusion. Delusions occur without hallucinations in about one-half to two-thirds of patients with psychotic depression. Hallucinations can be auditory, visual, olfactory (smell) or haptic (touch) and are congruent with the delusional material. Affection is sad, not flat. Strong anhedonialoss of interest and psychomotor retardation are typically present.

Cause

Psychotic symptoms tend to develop after an individual has had several episodes of depression without psychosis. However, once psychotic symptoms have arisen, they tend to reappear with each future depressive episode. The prognosis for psychotic depression it is not considered as bad as for schizoaffective disorders or primary psychotic disorders. Still, those who have experienced a depressive episode with psychotic features have an increased risk of relapse and suicide compared to those without psychotic features, and tend to have more pronounced sleep abnormalities.

Family members of those who have experienced psychotic depression are at greater risk for psychotic depression and schizophrenia.

Most patients with psychotic depression report having an initial episode between the ages of 20 and 40. Like other depressive episodes, psychotic depression tends to be episodic, with symptoms lasting for a period of time and then disappearing. Although psychotic depression can be chronic (lasting more than 2 years), most depressive episodes last less than 24 months. A study conducted by Kathleen S. Bingham found that patients who received adequate treatment for psychotic depression went into “remission”. They reported a similar quality of life to people without PD.

pathophysiology

There are a number of biological features that can distinguish psychotic depression from non-psychotic depression. The most significant difference may be the presence of an abnormality in the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis appears to be dysregulated in psychotic depression, with dexamethasone suppression tests demonstrating higher levels of cortisol after dexamethasone administration (ie, less cortisol suppression). Those with psychotic depression also have greater ventricle-brain relations than those with non-psychotic depression.

Diagnosis

Differential diagnosis

Psychotic symptoms are often missed in psychotic depression, either because patients don’t think their symptoms are abnormal or because they try to hide their symptoms from others. On the other hand, psychotic depression can be confused with schizoaffective disorder. Due to overlapping symptoms, the differential diagnosis also includes dissociative disorders.

Treatment

Several treatment guidelines recommend pharmaceutical treatments that include a combination of a second-generation antidepressant and an atypical antipsychotic or tricyclic antidepressant monotherapy or electroconvulsive therapy (ECT) as a first-line treatment for unipolar psychotic depression.

There is no evidence for or against the use of mifepristone.

Combined antidepressant and antipsychotic medications

There is some evidence indicating that combination therapy with an antidepressant plus an antipsychotic is more effective in treating psychotic depression than antidepressant treatment alone or placebo. In the context of psychotic depression, the following are the best studied antidepressant/antipsychotic combinations:

First generation

• Amitriptyline/perphenazine
• Amitriptyline/haloperidol

Second generation

• venlafaxine/quetiapine
• Olanzapine/fluoxetine
• olanzapine/sertraline

antidepressant medication

There is not enough evidence to determine whether treatment with an antidepressant alone is effective. Tricyclic antidepressants can be particularly dangerous because overdose has the potential to cause fatal cardiac arrhythmias.

antipsychotic medications

There is not enough evidence to determine whether treatment with antipsychotic medications alone is effective. olanzapine may be an effective monotherapy in psychotic depression, although there is evidence that it is ineffective for depressive symptoms as monotherapy; and olanzapine/fluoxetine is more effective. quetiapine monotherapy may be particularly useful in psychotic depression, as it has antidepressant and antipsychotic effects and a reasonable tolerability profile compared to other atypical antipsychotics. Current drug treatments for psychotic depression are reasonably effective, but they can cause side effects such as nausea, headaches, dizziness and weight gain.

Electroconvulsive therapy (ECT)

In modern ECT practice, a clonic therapy convulsion is induced by electrical current through electrodes placed on a person under anesthesia. Despite much research, the exact mechanism of action of ECT is still not known. ECT carries the risk of transient cognitive deficits (eg, confusion, memory problems) in addition to the burden of repeated exposures to general anesthesia.

Search

Efforts are made to find a treatment that targets the proposed specific underlying pathophysiology of psychotic depression. A promising candidate was mifepristonethat by competitively blocking certain neuroreceptors, it makes cortisol less able to act directly on the brain and was therefore thought to correct an overactive HPA axis. However, a Phase III clinical trial, which investigated the use of mifepristone in PMD, was terminated early due to lack of efficacy.

transcranial magnetic stimulation (TMS) is being investigated as an alternative to ECT in the treatment of depression. TMS involves administering an electromagnetic field focused on the cortex to stimulate specific nerve pathways.

Research has shown that psychotic depression differs from non-psychotic depression in several ways: potential precipitating factors, underlying biology, symptomatology beyond psychotic symptoms, long-term prognosis, and responsiveness to psychopharmacological treatment and ECT.

Prognosis

The long-term outcome for psychotic depression is generally worse than for non-psychotic depression.

References