Delusional depression

Journal o/Affeciive Elsevier

79

Disorders, 9 (1985) 79-83

JAD 00303

Delusional

Depression

A One Year Follow-up Delbert G. Robinson’

and Duane G. Spiker *

’ Department of Psychiatry,College of Physicians and Surgeons, Columbia University and New York State Psychiatric Institute, 722 W 168th Street, New York, NY 10032; and ’ Department of Psychiatry, University of Pitssburgh and Western Psychiatrtc Instttute and Clinic, 3811 O’Hara Street, Pittsburgh, PA 15213, U.S.A. (Received 2 October, 1984) (Accepted 19 December, 1984)

Summary Fifty-two unipolar delusional depressives were matched to 52 unipolar nondelusional depressives on the basis of sex, age at index episode of depression and age at first episode of depression. In a one year follow-up after discharge from inpatient treatment, the delusional depressives had a poorer clinical course than the nondelusional depressives as manifested by significantly higher rates both of major depression or delusions lasting longer than 9 months and of being in a major depressive episode at the end of the follow-up period.

Key words:

Delusional depression - Follow-up - Major depression

Introduction In recent years, the relationship between psychotic and nonpsychotic subtypes of major depressive disorders has attracted renewed scientific interest. Areas studied have included (1) the clinical characteristics of index episodes or past episodes of depression (Guze et al. 1975; Nelson and Bowers 1978; Charney and Nelson 1981; Glassman and Roose 1981; Roose et al. 1983), (2) the pharmacologic response to antidepressants (Glassman et al. 1975; Spiker et al. 1985) and (3) the neurobiologi-

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cal profiles (Meltzer et al. 1976; Sweeny et al. 1978) of psychotic vs nonpsychotic subtypes of depression. In addition to these possible areas of divergence, the question of a differential clinical outcome between psychotic and nonpsychotic subtypes of major depression has been raised. Coryell et al. (1982) reported a poorer short-term but equal long-term recovery rate for delusional vs nondelusional depressives who were part of the Iowa 500 cohort hospitalized between 1935 and 1940. Murphy (1983) found a poorer one year outcome for delusional compared to nondelusional geriatric depressives. To clarify further this issue of both scientific and public health importance, this paper will report on a study comparing the clinical course over one year of a group of 52

B.V. (Biomedical

Division)

x0

unipolar patients who had received treatment for an episode of delusional major depression with a matched control group of 52 unipolar patients who had received treatment in the same setting for a nonpsychotic episode of major depression. Methods

The study population consisted of a group of 52 patients who were admitted to the Clinical Research Unit (CRU) of Western Psychiatric Institute and Clinic between 1974 and 1982. All patients fulfilled Research Diagnostic Criteria fo. a definite diagnosis of major depressive disorder, unipolar subtype. Patients with a past definite diagnosis of hypomania were excluded from the sample. In addition, subjects also met criteria for psychotic subtype of major depressive disorder based on the presence of delusions. Thus, patients with only hallucinations or depressive stupor were not included. The study population of delusional depressives was obtained by screening the records of all patients of the CRU evaluated from 1974 to 1980 for inclusion into research protocols of pharmacologic treatments of major depressive episodes. From this group. all patients who fulfilled the above criteria for a delusional unipolar depression and who were referred for follow-up at Western Psychiatric Institute and Clinic after discharge from the CRU were included in the study population. Additionally, to decrease any bias in sample composition by initial status as research protocol patients or by preferred outpatient follow-up site, the records of all patients of the CRU from 1980 through 1982 were screened. All patients from this group who met criteria for an episode of delusional unipolar depression were included in the study sample without regard to whether they had been considered for a research protocol or where they had been referred for outpatient care. Using these criteria, a group of 52 patients was obtained. This group included 19 males and 33 females. Age distribution was from 19 to 69 years with an average age of 45.6 years. The control group consisted of patients who had been admitted to the CRU from 1974 to 1982 who fulfilled Research Diagnostic Criteria for major depressive disorder, unipolar subtype, but

who did not have any history of delusions, hallucinations or depressive stupor either during their index or past episodes of depression. Nondelusional controls were matched to delusional patients on the basis of sex. age at index episode of depression and also by age at first episode of depression. Matching of subjects using both age at first episode of depression and index episode of depression was done in an attempt to control for cycle frequency in preparation for a long-term follow-up of the delusional depressives. This strategy was chosen based on the findings of Grof et al. (1974) that for unipolar depressives, age at first episode of illness as well as current age and past number of episodes profoundly influence cycle frequency. The follow-up period began with the patient’s discharge from the CRU after having received treatment for their episode of depression. The follow-up was a naturalistic study with both the delusional and nondelusional patients receiving open treatment during the follow-up period with whatever treatment their psychiatrist deemed best. Information concerning the period of one year from the time of discharge from the CRU was collected from all available sources in the following areas: number of suicide attempts, number of rehospitalizations, clinical status at one year and over the course of the first year post discharge. To rate the clinical status of the patients over the course of the first year post discharge, 2 composite categories were used. The first of these, chronically-ill, was defined as the patient being symptomatic of either psychosis only or a major depressive episode with or without delusions continuously for 9 months or longer during the follow-up period. Episodically-ill, the second composite category, includes episodes of psychosis or major depression lasting less than 9 months. Patients rated as having a major depression in the chronically-ill category were required to meet full syndrome criteria for the 9 months. Chronic patients who had a partial resolution of their major depressive symptoms were rated as still having a major depression if they had syndromal criteria for a minor depressive disorder and this lasted less than one month. Otherwise, they would be included in the episodically-ill category. In addition to episodes of psychosis or major depression, epi-

sodes of minor depression were also included in the episodically-ill category with the stipulation that if a patient had both an episode of major depression and an episode of minor depression, they would be rated for the major depressive episode. In rating clinical status at the end of the first year, a cross-sectional approach was taken. Thus, patients who had a partial resolution of a major depression would be rated as having a minor depressive disorder if they fulfilled minor depressive criteria instead of being rated as still having a major depression. Results

Results are presented in the accompanying chart. Statistical analyses were performed using chi-square and t-tests where appropriate. Discussion

As can be noted from Table 1, the nondelusional depressives had a significantly higher chance than the delusional depressives of remaining asymptomatic over the course of the one year follow-up period. In examining symptom patterns present over the course of the first year, the delusional depressives were significantly more likely than the nondelusional depressives of being chronically ill. In addition, when looking at clinical diagnosis at the end of the one year follow-up, the delusional depressives were significantly more likely than the nondelusional depressives to have a major depression. In examining the 15 delusional depressives who followed a chronically-ill pattern over the one year follow-up period, several points are noteworthy. First, 80% (12 of 15) of the patients developed this course as a relapse of symptoms after an initial good response to the inpatient treatment which all patients received prior to beginning the follow-up period. In only 3 of the 15 chronically ill patients was the chronically-ill clinical course a continuation of a pattern of lack of response to treatment before beginning the follow-up period. Second, there was no significant difference in age between delusional depressives who had a chronically-ill course and those who did not have a chronically-ill

course (mean age of chronic patients, 48.5 f 17.5; mean age of nonchronic patients, 44.4 k 12.1; f = 0.96, P = 0.3, rif= 49). Third, the tendency of the delusional depressives to become chronically ill over the follow-up period occurred in both sexes with 6 males and 9 females showing this pattern (x’ = 0.108, P > 0.2). Finally, although the study was naturalistic and treatment regimes varied, the use of ECT in our patients did not affect development of a chronically-ill pattern. In the sample, 27% (4 of 15) of the patients who followed a chronically-ill pattern had been given ECT as part of their inpatient treatment prior to the follow-up. Similarly, 27% (10 of 37) of the patients who did not follow a chronic pattern had initially been treated with ECT. The majority of the 15 chronically ill delusional patients remained symptomatic at the end of the one year follow-up with 11 having symptoms of a major depressive episode and 1 being delusional without affective symptoms. However, 3 patients did show improvement at the end of one year with 1 of them having minor depressive symptoms and 2 being asymptomatic. Looking at the 15 delusional patients with major depressive symptoms at the end of the one year follow-up, 11 had been chronically ill during the preceding year, 2 had relapsed just at the end of one year after being asymptomatic for the prior year and the remaining 2 had had episodes of major depression episodically over the prior year. In reviewing the other variables besides clinical diagnoses over the follow-up period. no significant differences between the delusional and nondelusional depressives were found. However, consistent with the poorer clinical response of the delusional depressives, there was a trend (P < 0.10) for the delusional depressives to have a higher total number of hospitalizations over the one year follow-up period than the nondelusional depressives. From a retrospective study, Roose et al. (1983) reported an increase relative risk of suicide in delusional versus nondelusional depressives. Although no significant differences in suicide attempts or completed suicides was found in our study, the power to detect such a difference in our study was low given the rarity of suicide and the short risk period studied. However, concordant with Roose’s data, the one suicide in our delu-

82 TABLE

1

ONE YEAR

FOLLOW-UP

OF 52 DELUSIONAL

Are at index admission ( .Ui SD) Age at first depressive episode (X + SD) Male/female Clinical status over first year Asymptomatic Chronically-ill Episodically-ill Major depressive disorder Minor depressive disorder Delusional only Deceased/suicide Other Unknown Clinical status at end of first year Asymptomatic MaJor depressive disorder Minor depressive disorder Delusional only “ Deceased/suicide Other Unknown Suicide attempt/suicide Suicide attempt Suicide Hospitalized Patients hospitalized Total number hospitalizations ’ Did not have syndromal

criteria

UNIPOLAR

DEPRESSIVES

AND 52 MATCHED

CONTROLS

Delusional depressives

Nondelusional controls

P

45.6 + 14.2 39.2 k 13.4 19/33

45.8 + 13.5 38.0 * 13.9 19/33

ns nb “S

22 15 13 7 6 0

32 3 14 4 10 0 0 1 2

0.05 0.002 ns ns II ns ns ns n\

1 0 0

35 4 9 0 0 2 2

ns 0.005 ns ns ns ns “b

2 1

1 0

nh “s:

11 18

7 10

ns ns

1 1 0 29 15 6

for maJor or minor depression

sional group occurred at a time when the patient appeared to be clinically much improved. In order not to engender undue clinical pessimism, it is important to remember that 55% of the delusional depressives were asymptomatic at the end of the first year. However, the decidedly poorer clinical response of the delusional depressives compared to the nondelusional depressives in our study as evidenced by higher rates both for being chronically ill and for having a major depression at the end of the one year follow-up as well as a trend toward an increased number of hospitalizations underlines the need for further study of both the natural history and the maintenance treatment requirements of delusional depressives.

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