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, treatment should include a combination of antipsychotic and antidepressant medications or ECT.

BAP (Cleare et al., 2015)

In psychotic depression combine an antidepressant with an antipsychotic initially in preference to treating with an antidepressant alone or an antipsychotic alone.

Treatment of Guidelines for Psychotic Depression

Treatment of Guidelines for Psychotic Depression

First-line       

Tricyclic with olanzapine or quetiapine

Second choice        

SSRI/SNRI

Consider

Electroconvulsive therapy           

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).