1. D Green MD

2. 1. Review 2 cases of psychotic depression 2. Learn about epidemiology and presentation of psychotic depression 3. Review the treatment of this condition 4. Learn about prognosis and long term management of psychotic depression

3.  62 year old man originally from Africa presents to the clinic in March 2015 with a 2 month history of worry, insomnia, restlessness and poor concentration and placed briefly on Wellbutrin  By May 2015 more anxious and overwhelmed, decreased appetite, denies hallucinations or suicidal ideation

4.  Screening bloodwork done (negative) and started on Celexa 10 mg and referred to community psychiatrist  Depression and anxiety worsened and by November 2015 reported that thoughts were “intruding” into his head  Some thoughts of self-harm with no plan  Referred to Shared Mental Health Team

5.  By January 20 th, 2016 reporting auditory hallucinations telling him that he would be “better off dead”  Seen by SMH psychiatrist March 2016 ◦ Reporting command hallucinations e.g. several days before heard voice ( male voice speaking is native language) which had commanded him to climb a tree during the night ◦ Described some paranoia

6.  March 2016 ◦ Passive SI ◦ Not sleeping well ◦ PHQ-9 score of 25 ◦ Past psychiatric history significant for 2 lengthy admissions in Africa for what sounded like psychosis associated with losses

7.  60 year old female presents to clinic very anxious and overwhelmed with prominent theme of guilt about things not done to help various ill family members  Placed on Cipralex and later olanzapine was added given her high level of distress  Eventually admitted and treated with antidepressant and antipsychotics before eventually responding to a course of ECT

8.  One or more major depressive episodes and no history of mania or hypomania  Specifiers ◦ With anxious distress ◦ With atypical features ◦ With catatonia ◦ With mixed features ◦ With peripartum onset ◦ With seasonal pattern ◦ With psychotic features (delusions and/or hallucinations)

9.  More common in females  Point and lifetime prevalence of 0.4%  Some studies find it more common in individuals >60  In community surveys of individuals ill with unipolar major depression approximately 15- 20 percent had psychotic features

10.  Symptoms of major depression in unipolar psychotic depression are more numerous and more intense including: ◦ Suicidal ideation ◦ Hopelessness ◦ Cognitive impairment ◦ Insomnia ◦ Somatic complaints and hypochondriasis ◦ impulsivity

11.  Psychotic features ◦ Delusions ◦ Hallucinations, usually auditory  Psychotic features are often missed  Symptoms may be subtle and intermittent  Patients may conceal symptoms out of concern of being labelled “crazy”  Delusions are often plausible ◦ “I’ve committed a crime” ◦ “My neighbours are harassing me” ◦ Distinguishing between delusional and non-delusional guilt can be difficult at times

12.  Psychotic features  Content is typically mood-congruent with themes of:  Worthlessness  Guilt  Deserved punishment  Nihilism (impending disaster)  hopelessness

13.  Psychotic features ◦ Mood incongruent features can also be present at times. Examples include:  Thought insertion  Thought broadcasting  Delusions of control

14.  Suicidality ◦ Often accompanied by suicidal ideation or attempts ◦ Associated with:  Male gender  Past suicide attempt  Greater severity of depressive symptoms  Rate of completed suicide does not appear to be greater than non-psychotic depression

15.  Ask the patient about “strange or irrational worries” rather than “psychosis”  Interview family member or friend for collateral if suspect psychosis, if possible  Psychiatric and general medical history  Mental status and physical exam  Laboratory tests

16.  Risk assessment critical  Inpatient admission for severe symptoms and if significant risk present  If suspect contact SMH to discuss case and possibility of urgent assessment  Low quality studies comparing ECT vs. combined antidepressant with antipsychotic medication found similar responses  Combined pharmacotherapy generally selected as initial treatment as easier to administer, more widely available and more acceptable to patient

17.  ECT has a more rapid response and indicated for: ◦ Severe psychosis that places patient at imminent risk of harm ◦ Severe suicidality ◦ Malnutrition secondary to food refusal ◦ Previous response to ECT

18.  Medications: ◦ Sertraline plus olanzapine ◦ Fluoxetine plus olanzapine ◦ Venlafaxine plus quetiapine ◦ Amitriptyline plus haloperidol ◦ Amitriptyline plus perphenazine

19.  50 per cent recover with 2 to 3 months  Large majority recover with 6 to 12 months  A few remain ill for 10 years or longer  Functional recovery often lags behind recovery from psychotic and depressive symptoms  Better recovery likely if: ◦ Age between 30 and 65 ◦ Good premorbid functioning ◦ First time episode ◦ Good response to treatment

20.  Psychotic depression associated with significantly more recurrences of major depression than non-psychotic depression  Often psychotic during subsequent recurrences of major depression

21.  For patients with psychotic depression who remit the recommendation is to continue both the antidepressant and the antipsychotic for 4 months and then try to gradually withdraw the antipsychotic (STOP-PD study)  Antidepressant is usually maintained for at least 2 years

22.  While relatively uncommon it is important to recognize psychotic depression  Assess patients with more numerous and severe depressive symptoms carefully for psychotic symptoms  Treatment with both antidepressant and antipsychotic medication necessary with ECT reserved for more severe cases  If suspect contact SMH to discuss or for assessment