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Recurrent psychotic depression
Journul of Affectroe Dmvders, Elsevier Biomedical Press
Recurrent Evidence
Paul Department
51
5 (1983) 5 l-54
Psychotic Depression of Diagnostic
M. Helms
Stability
and Robert
E. Smith
of Psychratry, Unrversrty 01 Iowa, 500 Newton Road, Iowu Clt_y. IA 52242 (U,S.A ) (Recewed (Accepted
18 May, 1982) 18 June. 1982)
Summary A review of the research comparing psychotic and nonpsychotic depression gives considerable evidence to support the view that these groups are distinct diagnostic subtypes. A representative sample of the research favoring this view is presented. Particular note is made of Charney and Nelson’s data on stability of diagnosis. Our finding of 92.3% of psychotic depressives experiencing previous and/or subsequent psychotic episodes is consistent with Charney and Nelson’s findings. Additional support for stability of diagnosis is the rare occurrence of nonpsychotic depression found after the index psychotic admission. Clinical and research implications are discussed.
Introduction There has been considerable interest in the possibility of psychotic depression representing a diagnostic subtype distinct from nonpsychotic depression (Charney et al. 198 1; Frances et al. 198 1; Glassman et al. 198 1). Support for this view comes from a number of studies showing a relatively poor response of psychotic depression to tricyclic antidepressants alone (Kantor et al. 1977; Avery et al. 1979; Minter et al. 1979; Charney et al. 198 1; Frances et al. 198 1; Glassman et al. 1981). Quantification of presenting symptomatology by the Hamilton Depression Scale indicates psychotic depressives to be more severely ill than those without psychotic features (Charney et al. 198 1; Frances et al. 1981; Glassman et al. 1981). Coryell and Tsuang (in press)
Reprints
to: Robert
E. Smith, M.D.
0165-0327/83/0000-0000/$03.00
0 1983 Elsevler Biomedical
Press
52
found that nonpsychotic depressives appeared better at discharge and on short term follow-up, but found no difference at 40-year follow-up. The biochemical data supporting psychotic depression as a separate subtype has shown psychotic depressives to have lower urinary 3-methoxy-4-hydroxyphenethylene glycol (MHPG) (Deleon-Jones et al. 1975; Sweeney et al. 1978), higher CSF homovanillic acid (HVA) (Sweeney et al. 1978) and lower serum dopamine-/3-hydroxylase (Meltzer et al. 1976) than nonpsychotic depressives. Research comparing the number of previous episodes is conflicting. Guze and associates (1975) and Nelson and Bowers (1978) found the psychotic group to have more previous episodes than the nonpsychotic group, where as Coryell and Tsuang (in press) found the opposite. A possible explanation for the difference between Nelson and Bowers’ finding and that of Coryell and Tsuang is the age at index admission, 54.6 and 43.8 year, respectively. The 10.8 year difference indicates a longer period for Nelson and Bowers’ group to experience previous episodes and permit a different pattern to emerge. Since no age at index admission was reported by Guze and associates we are unable to determine if this could be a factor in this study as well. Charney and Nelson (1981) demonstrated a significantly greater occurrence of previous psychotic depressions in patients whose index admission was for a psychotic depression than those admitted for a nonpsychotic depression. A previous psychotic episode occurred in 95% and 8%, respectively (P < 0.001). Our study was undertaken to evaluate the question of stability of psychotic features during recurrent depressive episodes in light of Charney and Nelson’s findings.
Method
All admissions to the University of Iowa Psychiatric Hospital between July 1, 1973 and June 30, 1978 were reviewed for a chart diagnosis of depression. A research assistant screened the charts for a Research Diagnostic Criteria (RDC) diagnosis of psychotic major depressive disorder. The definition of psychosis by RDC is the presence of delusions or hallucinations. Those with a suspected or confirmed diagnosis of mania/hypomania, schizophrenia, or organic psychosis were excluded. Nonindex admissions at the University of Iowa were also diagnosed by RDC and all diagnosis were corroborated by the authors. Only patients with two or more admissions for separate depressive episodes were included. To be considered a separate episode the patient had to be symptom free for two or more months on or off medication. Due to the sample size and the small expected frequencies, the Fisher’s exact test was used to analyze discrete data.
Results
There were 61 patients who fulfilled RDC criteria for a psychotic major depressive disorder on at least one admission between July 1, 1973 and June 30, 1978. Thirteen of these met all criteria for inclusion into the study. The mean age at index admission was 45.9 c 15.5 years. Due to the limited
53 TABLE
1
COMPARISON
Previous Subsequent P =0.0097.
OF PREVIOUS
AND
SUBSEQUENT
ADMISSIONS
PsychotIc
Mlxed,/nonpsychotlc
1 11
4 1
Fisher’s exact test.
number of previous episodes both previous and subsequent admissions were reviewed for other psychotic depressive episodes. Twelve of 13 (92.3%) patients had other such episodes. There were 23 other admissions for depressive episodes. Eighteen (78.3%) of these were psychotic. Previous admissions were purely psychotic in one patient, mixed (both psychotic and nonpsychotic) admissions in one and nonpsychotic in three. Subsequent admissions were psychotic in eleven patients and mixed in one. Table 1 shows the comparison between previous and subsequent episodes as a function of whether the episodes were purely psychotic or not (mixed or purely nonpsychotic). The difference is significant (P =C0.01) demonstrating that while four patients experience at least one nonpsychotic depression prior to the index admission only one did after the index admission. This, in fact, represented one depressive episode which occurred while the patient was on a combination of amitriptyline and perphenazine.
Discussion
The finding that 92.3% of psychotic depressives with recurrent illness experienced another admission for a psychotic depression is consistent with Charney and Nelson’s 95% figure. We justified comparing previous and subsequent admissions m our study with previous admissions in their study because of the difference in mean age at index admission (45.9 2 15.5 and 54.8 * 11.8 years, respectively) and the subsequently small number of previous admissions in our sample. Charney and Nelson reported that among the patients whose index admission was psychotic, 89% of all previous depressive episodes were psychotic as well. This would indicate that 11% were nonpsychotic which leaves the question of stability of diagnosis partially unanswered. Our finding of only one patient experiencing a subsequent nonpsychotic depressive episode would contribute to the conclusion that psychotic depression represents a stable subtype particularly since the antipsychotic, perphenazine, may have obscured any psychotic symptoms. There appears to be three possible interpretations of our results. First, psychotic symptoms may have been overlooked initially, but once detected, were looked for more rigorously on subsequent admissions. Second, psychotic depression may initially present in a milder form, but once psychotic features emerge they continue to do so during subsequent episodes. Both of these interpretations would be consistent
54
with viewing psychotic depression as a distinct entity. The third possibility is that depression may present variably in a mild to severe, i.e. psychotic, form. This interpretation would be consistent with a continuum theory, but does not appear to be supported by our results. Our results, along with other research on diagnostic stability, biochemical studies and tricyclic treatment studies, appear most compatible with psychotic depression representing a separate diagnostic subtype distinct from nonpsychotic depression. The findings of our study should be interpreted with some caution in view of the sample size and the retrospective nature of the study. If replicated, there are definite clinical as well as research implications. It would be of interest to evaluate the response to tricyclics in the nonpsychotic episodes to determine if it is more characteristic of psychotic or nonpsychotic depression. A patient with a previous psychotic depression should be rigorously evaluated for psychotic symptoms. Apart from any theoretical diagnostic implications, a patient who is extremely likely to develop psychotic symptoms during a depression would benefit from closer observation and more aggressive treatment.
References Avery, D. and Lumbrano, A., Depression treated with imtpramine and ECT - The DeCarohs study reconstdered, Amer. J. Psychiat., 136 (1979) 559-562. Charney, D S. and Nelson, J.C., Delusional and nondelusional umpolar depression - Further evtdence for dtstmct subtypes, Amer. J. Psychiat., 138 (1981) 328-333. Coryell, W. and Tsuang, M.T., Primary unipolar depresston and the prognosttc stgniftcance of delustons, Arch. Gen Psychiat., In press. Deleon-Jones, F., Maas, J.W., DektrmeriJian, H. and Sanchez, J., Dtagnosttc subgroups of affecttve dtsorders and their urinary excretton of catecholamine metabohtes. Amer. J. Psychiat., 132 (1975) 1141-1148. Frances, A., Brown, R.P., Kocts, J.H. and Mann, J.J., Psychottc depression - A separate enttty? Amer. J. Psychiat., 138 (1981) 831-833. Glassman, A.H and Roose, S.P., Delusional depresston A dtstmct chmcal enttty? Arch. Gen. Psychiat., 38 (1981) 424-427. Guze, S.B., Woodruff, R.A. and Clayton, P.J., The stgmftcance of psychottc affecttve dtsorders, Arch. Gen. Psychtat., 32 (1975) 1147-1150 Kantor, S.J. and Glassman, A.H., Delustonal depresston - Natural htstory and response to treatment, Brit J. Psychtat., 131 (1977) 351-360. Meltzer, H.Y., Cho, H.W., Carroll, B.J. and Russo, P., Serum dopamme-/3-hydroxylase activtty m the affecttve psychoses and schtzophrenia, Arch. Gen. Psychiat., 33 (1976) 585-591. Minter, R.E. and Mandel, M.R., The treatment of psychottc maJor depressive dtsorder with drugs and electroconvulsive therapy, J. Nerv. Ment. Dis., 167 (1979) 7266733. Nelson, J.C. and Bowers, M.B., Delusional umpolar depression - Descriptton and drug response, Arch. Gen. Psychtat., 35 (1975) 1321-1328 Sweeney, D, Nelson, C., Bowers, M., Maas, J. and Henmger, G., Delustonal versus nondelustonal depresston - Neurochemtcal differences (Letter), Lancet, it (1978) lOO- 101.
Recurrent Evidence
Paul Department
51
5 (1983) 5 l-54
Psychotic Depression of Diagnostic
M. Helms
Stability
and Robert
E. Smith
of Psychratry, Unrversrty 01 Iowa, 500 Newton Road, Iowu Clt_y. IA 52242 (U,S.A ) (Recewed (Accepted
18 May, 1982) 18 June. 1982)
Summary A review of the research comparing psychotic and nonpsychotic depression gives considerable evidence to support the view that these groups are distinct diagnostic subtypes. A representative sample of the research favoring this view is presented. Particular note is made of Charney and Nelson’s data on stability of diagnosis. Our finding of 92.3% of psychotic depressives experiencing previous and/or subsequent psychotic episodes is consistent with Charney and Nelson’s findings. Additional support for stability of diagnosis is the rare occurrence of nonpsychotic depression found after the index psychotic admission. Clinical and research implications are discussed.
Introduction There has been considerable interest in the possibility of psychotic depression representing a diagnostic subtype distinct from nonpsychotic depression (Charney et al. 198 1; Frances et al. 198 1; Glassman et al. 198 1). Support for this view comes from a number of studies showing a relatively poor response of psychotic depression to tricyclic antidepressants alone (Kantor et al. 1977; Avery et al. 1979; Minter et al. 1979; Charney et al. 198 1; Frances et al. 198 1; Glassman et al. 1981). Quantification of presenting symptomatology by the Hamilton Depression Scale indicates psychotic depressives to be more severely ill than those without psychotic features (Charney et al. 198 1; Frances et al. 1981; Glassman et al. 1981). Coryell and Tsuang (in press)
Reprints
to: Robert
E. Smith, M.D.
0165-0327/83/0000-0000/$03.00
0 1983 Elsevler Biomedical
Press
52
found that nonpsychotic depressives appeared better at discharge and on short term follow-up, but found no difference at 40-year follow-up. The biochemical data supporting psychotic depression as a separate subtype has shown psychotic depressives to have lower urinary 3-methoxy-4-hydroxyphenethylene glycol (MHPG) (Deleon-Jones et al. 1975; Sweeney et al. 1978), higher CSF homovanillic acid (HVA) (Sweeney et al. 1978) and lower serum dopamine-/3-hydroxylase (Meltzer et al. 1976) than nonpsychotic depressives. Research comparing the number of previous episodes is conflicting. Guze and associates (1975) and Nelson and Bowers (1978) found the psychotic group to have more previous episodes than the nonpsychotic group, where as Coryell and Tsuang (in press) found the opposite. A possible explanation for the difference between Nelson and Bowers’ finding and that of Coryell and Tsuang is the age at index admission, 54.6 and 43.8 year, respectively. The 10.8 year difference indicates a longer period for Nelson and Bowers’ group to experience previous episodes and permit a different pattern to emerge. Since no age at index admission was reported by Guze and associates we are unable to determine if this could be a factor in this study as well. Charney and Nelson (1981) demonstrated a significantly greater occurrence of previous psychotic depressions in patients whose index admission was for a psychotic depression than those admitted for a nonpsychotic depression. A previous psychotic episode occurred in 95% and 8%, respectively (P < 0.001). Our study was undertaken to evaluate the question of stability of psychotic features during recurrent depressive episodes in light of Charney and Nelson’s findings.
Method
All admissions to the University of Iowa Psychiatric Hospital between July 1, 1973 and June 30, 1978 were reviewed for a chart diagnosis of depression. A research assistant screened the charts for a Research Diagnostic Criteria (RDC) diagnosis of psychotic major depressive disorder. The definition of psychosis by RDC is the presence of delusions or hallucinations. Those with a suspected or confirmed diagnosis of mania/hypomania, schizophrenia, or organic psychosis were excluded. Nonindex admissions at the University of Iowa were also diagnosed by RDC and all diagnosis were corroborated by the authors. Only patients with two or more admissions for separate depressive episodes were included. To be considered a separate episode the patient had to be symptom free for two or more months on or off medication. Due to the sample size and the small expected frequencies, the Fisher’s exact test was used to analyze discrete data.
Results
There were 61 patients who fulfilled RDC criteria for a psychotic major depressive disorder on at least one admission between July 1, 1973 and June 30, 1978. Thirteen of these met all criteria for inclusion into the study. The mean age at index admission was 45.9 c 15.5 years. Due to the limited
53 TABLE
1
COMPARISON
Previous Subsequent P =0.0097.
OF PREVIOUS
AND
SUBSEQUENT
ADMISSIONS
PsychotIc
Mlxed,/nonpsychotlc
1 11
4 1
Fisher’s exact test.
number of previous episodes both previous and subsequent admissions were reviewed for other psychotic depressive episodes. Twelve of 13 (92.3%) patients had other such episodes. There were 23 other admissions for depressive episodes. Eighteen (78.3%) of these were psychotic. Previous admissions were purely psychotic in one patient, mixed (both psychotic and nonpsychotic) admissions in one and nonpsychotic in three. Subsequent admissions were psychotic in eleven patients and mixed in one. Table 1 shows the comparison between previous and subsequent episodes as a function of whether the episodes were purely psychotic or not (mixed or purely nonpsychotic). The difference is significant (P =C0.01) demonstrating that while four patients experience at least one nonpsychotic depression prior to the index admission only one did after the index admission. This, in fact, represented one depressive episode which occurred while the patient was on a combination of amitriptyline and perphenazine.
Discussion
The finding that 92.3% of psychotic depressives with recurrent illness experienced another admission for a psychotic depression is consistent with Charney and Nelson’s 95% figure. We justified comparing previous and subsequent admissions m our study with previous admissions in their study because of the difference in mean age at index admission (45.9 2 15.5 and 54.8 * 11.8 years, respectively) and the subsequently small number of previous admissions in our sample. Charney and Nelson reported that among the patients whose index admission was psychotic, 89% of all previous depressive episodes were psychotic as well. This would indicate that 11% were nonpsychotic which leaves the question of stability of diagnosis partially unanswered. Our finding of only one patient experiencing a subsequent nonpsychotic depressive episode would contribute to the conclusion that psychotic depression represents a stable subtype particularly since the antipsychotic, perphenazine, may have obscured any psychotic symptoms. There appears to be three possible interpretations of our results. First, psychotic symptoms may have been overlooked initially, but once detected, were looked for more rigorously on subsequent admissions. Second, psychotic depression may initially present in a milder form, but once psychotic features emerge they continue to do so during subsequent episodes. Both of these interpretations would be consistent
54
with viewing psychotic depression as a distinct entity. The third possibility is that depression may present variably in a mild to severe, i.e. psychotic, form. This interpretation would be consistent with a continuum theory, but does not appear to be supported by our results. Our results, along with other research on diagnostic stability, biochemical studies and tricyclic treatment studies, appear most compatible with psychotic depression representing a separate diagnostic subtype distinct from nonpsychotic depression. The findings of our study should be interpreted with some caution in view of the sample size and the retrospective nature of the study. If replicated, there are definite clinical as well as research implications. It would be of interest to evaluate the response to tricyclics in the nonpsychotic episodes to determine if it is more characteristic of psychotic or nonpsychotic depression. A patient with a previous psychotic depression should be rigorously evaluated for psychotic symptoms. Apart from any theoretical diagnostic implications, a patient who is extremely likely to develop psychotic symptoms during a depression would benefit from closer observation and more aggressive treatment.
References Avery, D. and Lumbrano, A., Depression treated with imtpramine and ECT - The DeCarohs study reconstdered, Amer. J. Psychiat., 136 (1979) 559-562. Charney, D S. and Nelson, J.C., Delusional and nondelusional umpolar depression - Further evtdence for dtstmct subtypes, Amer. J. Psychiat., 138 (1981) 328-333. Coryell, W. and Tsuang, M.T., Primary unipolar depresston and the prognosttc stgniftcance of delustons, Arch. Gen Psychiat., In press. Deleon-Jones, F., Maas, J.W., DektrmeriJian, H. and Sanchez, J., Dtagnosttc subgroups of affecttve dtsorders and their urinary excretton of catecholamine metabohtes. Amer. J. Psychiat., 132 (1975) 1141-1148. Frances, A., Brown, R.P., Kocts, J.H. and Mann, J.J., Psychottc depression - A separate enttty? Amer. J. Psychiat., 138 (1981) 831-833. Glassman, A.H and Roose, S.P., Delusional depresston A dtstmct chmcal enttty? Arch. Gen. Psychiat., 38 (1981) 424-427. Guze, S.B., Woodruff, R.A. and Clayton, P.J., The stgmftcance of psychottc affecttve dtsorders, Arch. Gen. Psychtat., 32 (1975) 1147-1150 Kantor, S.J. and Glassman, A.H., Delustonal depresston - Natural htstory and response to treatment, Brit J. Psychtat., 131 (1977) 351-360. Meltzer, H.Y., Cho, H.W., Carroll, B.J. and Russo, P., Serum dopamme-/3-hydroxylase activtty m the affecttve psychoses and schtzophrenia, Arch. Gen. Psychiat., 33 (1976) 585-591. Minter, R.E. and Mandel, M.R., The treatment of psychottc maJor depressive dtsorder with drugs and electroconvulsive therapy, J. Nerv. Ment. Dis., 167 (1979) 7266733. Nelson, J.C. and Bowers, M.B., Delusional umpolar depression - Descriptton and drug response, Arch. Gen. Psychtat., 35 (1975) 1321-1328 Sweeney, D, Nelson, C., Bowers, M., Maas, J. and Henmger, G., Delustonal versus nondelustonal depresston - Neurochemtcal differences (Letter), Lancet, it (1978) lOO- 101.