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Treatment of Psychotic Depression

Cochrane Review 2015(Wijkstra J 2015) Psychotic depression is heavily understudied, limiting confidence in the conclusions drawn. Evidence suggests that combination therapy with an antidepressant plus an antipsychotic is more effective than either treatment alone or a placebo. Evidence for treatment with an antidepressant alone or for an antipsychotic alone is lacking. Maudsley Prescribing Guidelines 2018(Taylor 2018) Tricyclic augmented by olanzapine or quetiapine as the first line If tricyclic is not well tolerated, use SSRI or SNRI instead NICE For people who have depression with psychotic symptoms, consider augmenting the current treatment plan with antipsychotic medication (although the optimum dose and duration of treatment are unknown). CANMAT 2016 Use antipsychotic and antidepressant cotreatment (Level 1 evidence) APA Practice Guidelines for Major Depressive Disorder, 2010 For patients who exhibit psychotic symptoms during an episode of major depressive disorder, treatme

Guidelines for the Pharmacotherapy of Major Depressive Disorder

Guidelines for the Pharmacotherapy of Major Depressive Disorder I have summarised the following recommendations from the Maudsley prescribing guidelines in Psychiatry, 13th Ed. Psychotherapies Supportive psychotherapy, CBT, interpersonal therapy, marital/couple therapy, dynamic psychotherapy, behavioral activation Depressive episode Step-1 SRI/ Mirtazapine à A generic SRI; use mirtazapine if sleep needed Step-2 SSRI/non-SRI   à Most evidence is for a switch to vortioxetine Step 3 Mirtazapine, vortioxetine, agomelatine   à if not already trialed

Patient Health Questionnaire 9 (PHQ-9)

Patient Health Questionnaire-9  (PHQ-9; Kroenke, Spitzer, & Williams, 2001).  The Patient Health Questionnaire-9 is a 9-item self-report measure assessing depressive symptoms in adults.   The Patient Health Questionnaire-9 can be used as a screening tool, a diagnostic tool, and to monitor symptom change over time. There exists a separate version for the Patient Health Questionnaire-9 for adolescents within the Patient Health Questionnaire-Adolescent Version. Sample items include: “Little interest or pleasure in doing things” and “Feeling down, depressed, or hopeless.”  Each item is rated on a scale from zero (“not at all”) to three (“nearly every day”).  Total scores range from 0-27.  Meta-analysis of the PHQ-9 diagnostic accuracy compared to independent mental health professional diagnosis demonstrates good criterion validity with a sensitivity of 77% and a specificity of 94 %.  The PHQ is also validated as an 8- and 2-item measure to assess depression severity.  The measures are

Vignette: Assessment of Depression

A 33-year-old man who is a driver-by-profession presented to you with decreased appetite, loss of sleep, and irritability for the last three months. There is no past or family history of psychiatric conditions. He is the only earning member of his family and must go to work every day to make a living. On physical examination, his pulse is 90 beats per minute with an irregular rhythm. a) Outline your assessment and management plans. b) What precautions you will take while prescribing psychotropic medications in this case? c) Enumerate all possible differential diagnoses in this case.

Delusions in Psychotic Depression

(Mnemonic: GINPH) ● Delusions of Guilt ● Delusions of Impoverishment (can also be considered as a type of nihilistic delusion. ● Nihilistic delusions, including Cotard syndrome ● Persecutory delusions* ● Hypochondriacal delusions Patients with Psychotic depression  consider these thoughts well-deserved unlike in schizophrenia where patients feel remorse towards them and mania where patients consider them a response to the great position they have earned.  When these delusions occur against a background of depressed mood, they are mood-congruent and favor the diagnosis of psychotic depression. When patients with depression have delusions of grandeur or even neutral delusions e.g. delusions of reference, they are mood-incongruent delusions" and favor the diagnosis of schizophrenia (ICD-10).

Hamilton Scale for Depression

Hamilton Scale for Depression HAMD or HDRS was developed by Max Hamilton in 1960 ● Clinician-rated, unlike Beck scales which are self-rated ● It starts with an item on depression and ends with one on obsessive-compulsive symptoms. ● The most widely used clinician-administered depression assessment scale. ● The original version contains 17 items (HDRS17) pertaining to symptoms of depression experienced over the past week. The HDRS was originally developed for hospital inpatients, thus the emphasis on melancholic and physical symptoms of depression. A later 21-item version (HDRS21) included 4 items intended to subtype the depression, but which are sometimes, incorrectly, used to rate severity. ● Only the first 17 should be used to measure the severity ● A limitation of the HDRS is that atypical symptoms of depression (e.g., hypersomnia, hyperphagia) are not assessed. Scoring  ● The method for scoring varies by version. For the HDRS17, a score of 0–7 is generally accepted to be wi

Classification of Depression According to the ICD-10

A first depressive episode, duration at least15 days →depressive episode (F32)  A first depressive episode, severe and rapid onset, duration less than 15 days →still depressive episode (F32) A depressive episode can be mild (2 core symptoms, 2 other symptoms from the list) (32.0) moderate (2 core symptoms, 3 or preferably 4 other symptoms) (32.1) Severe (3 core symptoms, 4 other symptoms) without psychotic symptoms (32.2) (no delusion, hallucination or stupor) Severe with psychotic symptoms (above plus either delusions, hallucinations or stupor) (F32.3) Delusions can be mood-congruent or incongruent (neutral delusions e.g. delusions of reference are considered mood incongruent. None of them count towards schizoaffective disorder unless one of the first-rank)  A mild and moderate depressive episode can be  with somatic syndrome (four or more somatic symptoms, or three very severe somatic symptoms) without somatic syndrome (three or less somatic symptoms, not severe)  A severe depressi

Difference between Grief Reaction and Depression

Predominant mood in grief is feelings of emptiness and loss , while in depression, one has a persistent low mood and anhedonia .  Mood in greif improves over days to weeks in waves , while it is persistent in case of depression. In greif there may be waves of positive feelings including humor as compared to depression where , there is only low mood.  The grieved person is preoccupied with memories of the deceased, depression on the other hand is characterised by the depressive cognitions of guilt, pessimism, hopelessness, worthlessness.