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Risk of Psychosis in Major Depression
Brian Miller, MD, PhD, MPH
New findings raise the question of the optimal treatment for prevention of future psychotic depressive episodes.
New findings raise the question of the optimal treatment for prevention of future psychotic depressive episodes.
• Psychotic depression may be a distinct subtype of depression that is (semi-)independent of illness severity[1]
• There is some evidence that patients with current psychotic depression are more likely to have a history of prior psychotic depressive episodes, compared with patients with nonpsychotic depression, but this topic has not been systematically reviewed
• Nelson and colleagues[2] performed a systematic review of the course of illness in psychotic depression and a meta-analysis of (a) the frequency of psychosis in prior or subsequent episodes in psychotic or nonpsychotic major depression, and (b) the frequency of all episodes of depression in these two groups
• The authors searched PubMed, Embase, and PsycINFO from inception until June 2015, and again in May 2017
• Studies in English were selected if they identified patients with unipolar major depression using DSM-III, DSM-IV, RDC, or Washington University criteria; identified psychotic and nonpsychotic patients based on the presence of hallucinations or delusions; and characterized past or subsequent episodes of depression as psychotic or nonpsychotic
• The episode at the time of study entry was considered the index episode
• The authors first performed a random effects meta-analysis of the risk of any prior or subsequent psychotic depressive episode in patients whose index episode was psychotic (versus nonpsychotic)
• A random effects meta-analysis of the risk of psychosis in all episodes (prior or subsequent) in patients whose index episode was psychotic (versus nonpsychotic) was then performed
• Secondary analyses were conducted to investigate the effects of study type (retrospective versus prospective), age, and year of publication
• The authors reviewed 144 articles in full, of which 12 studies met the inclusion criteria
• Studies comprised 546 patients with psychotic depression and 1583 patients with nonpsychotic depression
• Univariate regression analyses were used to evaluate baseline (and change in) inflammatory marker
• Mean subject age was 49, and two-thirds of patients were female
• Patients with a psychotic (versus nonpsychotic) index episode were ten times more likely to have at least one prior or subsequent psychotic episodes (65% versus 5%, RR=9.98, 95% CI 4.75-20.94)
• Patients with a psychotic (versus nonpsychotic) index episode had over seven-fold increased risk of psychosis among all episodes of depression (64% versus 6%, RR=7.24, 95% CI 5.03-10.43)
• Between-study heterogeneity was significant for both analyses
• The authors concluded that psychotic depression runs “true to form,” that is, there is a significantly higher risk of psychosis among patients whose index depressive episode was psychotic compared with those whose index episode was nonpsychotic
• Findings suggest stability of the diagnosis of psychotic depression
• 64% of all episodes in patients with psychotic index depressive episodes were psychotic
• Findings raise the question of the optimal treatment for prevention of future psychotic depressive episodes
REFERENCES
1. Charney DS, Nelson JC. Delusional and nondelusional unipolar depression: further evidence for distinct subtypes. Am J Psychiatry. 1981;138:328–333.
2. Nelson JC, Bickford D, Delucchi K, et al. Risk of psychosis in recurrent episodes of psychotic and nonpsychotic major depressive disorder: a systematic review and meta-analysis. Am J Psychiatry. 2018;175:897–904.