Savvy Psychopharmacology

Management of major depressive disorder with psychotic features

Current Psychiatry. 2021 February;20(2):30-33 | doi:10.12788/cp.0092

References

1. Diagnostic and statistical manual of mental disorders, 5th ed. American Psychiatric Association; 2013.
2. Jääskeläinen E, Juola T, Korpela H, et al. Epidemiology of psychotic depression - systematic review and meta-analysis. Psychol Med. 2018;48(6):905-918.
3. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry. 2000;157(4)(suppl):1-45.
4. National Institute for Clinical Excellence. Depression in adults: recognition and management: clinical guideline [CG90]. National Institute for Health and Clinical Excellence. Published October 28, 2009. Accessed January 12, 2021. https://www.nice.org.uk/guidance/cg90
5. Crimson ML, Trivedi M, Pigott TA, et al. The Texas Medication Algorithm Project: report of the Texas Consensus Conference Panel on medication treatment of major depressive disorder. J Clin Psychiatry. 1999;60(3):142-156.
6. Meyers BS, Flint AJ, Rothschild AJ, et al. A double-blind randomized controlled trial of olanzapine plus sertraline vs olanzapine plus placebo for psychotic depression: the study of pharmacotherapy for psychotic depression -- the STOP-PD study. Arch Gen Psychiatry. 2009;66(8):838-847.
7. Rothschild AJ, Williamson DJ, Tohen MF, et al. A double-blind, randomized study of olanzapine and olanzapine/fluoxetine combination for major depression with psychotic features. J Clin Psychopharmacol. 2004;24(4):365-373.
8. Wijkstra J, Burger H, van den Broek WW, et al. Treatment of unipolar psychotic depression: a randomized, doubleblind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine. Acta Psychiatr Scand. 2010;21(3):190-200.
9. Muller-Siecheneder F, Muller M, Hillert A, et al. Risperidone versus haloperidol and amitriptyline in the treatment of patients with a combined psychotic and depressive syndrome. J Clin Psychopharm. 1998;18(2):111-120.
10. Spiker DG, Weiss JC, Dealy RS, et al. The pharmacological treatment of delusional depression. Am J Psychiatry. 1985;142(4):430-436.
11. Flint AJ, Meyers BS, Rothschild AJ, et al. Effect of continuing olanzapine vs placebo on relapse among patients with psychotic depression in remission: the STOP-PD II randomized clinical trial. JAMA. 2019;322(7):622-631.

Mrs. C, age 56, has a history of major depressive disorder (MDD). She has been stable for 5 years without medication. Six months ago, she presented to you, along with her son, seeking help. She reported that she had been experiencing insomnia, fatigue, and was not engaging in hobbies. Her son told you that his mother had lost weight and had been avoiding family dinners. Mrs. C reported recurrent thoughts of dying and heard voices vividly telling her that she was a burden and that her family would be better off without her. However, there was no imminent danger of self-harm. At that appointment, you initiated sertraline, 50 mg/d titrated to 100 mg/d, and olanzapine, 5 mg/d.

Since that time, Mrs. C has followed up with you monthly with good response to the medications. Currently, she states her depression is much improved, and she denies hearing voices for approximately 5 months.

Based on her presentation and response, what do the data suggest about her length of treatment, and when should you consider tapering the antipsychotic medication?

In DSM-5, MDD with psychotic features is a severe subtype of MDD that is defined as a major depressive episode characterized by delusions and/or hallucinations.¹ In the general population, the lifetime prevalence of this disorder varies from 0.35% to 1%, and the rate is higher in older patients.² Risk factors include female gender, family history, and concomitant bipolar disorder.²

Epidemiologic studies have shown that psychotic features can occur in 15% to 20% of patients with MDD. The psychotic features that occur during these episodes are delusions and hallucinations.¹ These features can be either mood-congruent (related to the depressive themes of worthlessness or guilt) or mood-incongruent (ie, unrelated to depressive themes).¹

Treatment options: ECT or pharmacotherapy

Guidelines from the American Psychiatric Association³ and the National Institute for Clinical Excellence⁴ recommend treating depression with psychosis with electroconvulsive therapy (ECT) or with combined antidepressant and antipsychotic medications as first-line options. The Texas Medication Algorithm Project (TMAP) Algorithm for MDD,⁵ which closely focuses on treatment of MDD with psychotic features, can be used for treatment decisions (see Related Resources).

Electroconvulsive therapy is known to be efficacious in treating patients with MDD with psychotic features and should be considered as a treatment option. However, medication therapy is often chosen as the initial treatment due to the limitations of ECT, including accessibility, cost, and patient preference. However, in certain cases, ECT is the preferred option because it can provide rapid and significant improvement in patients with severe psychosis, suicidality, or risk of imminent harm.

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Management of major depressive disorder with psychotic features

References

Treatment options: ECT or pharmacotherapy

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