Abstract
The clinical definition and the nosological status of psychotic depression remain unclear. A number of differences have been suggested between psychotic depression and non-psychotic depression [1]. These include variables such as age, sex, family history and endocrine factors such as hypothalamic, pituitary and adrenocortical abnormalities [2]. This study was designed to look at the long-term course of patients with psychotic depression.
The study was conducted in the Outpatient clinic of the Department of Psychiatry at the National Institute of Mental Health and Neurosciences (NIMHANS) Bangalore, India.
Thirty patients with an ICD-10 diagnosis of ‘severe depressive episode with psychotic symptoms’ (F32.3) and ‘recurrent depressive disorder, current severe episode with psychotic symptoms’ (F 32.3) were selected randomly.
The mean age of the study sample was 34 (SD ± 17), 70% were married, and 53% were male. Of the females, 57% were housewives or unemployed.
A previous history of unipolar depressive episode was documented in 30% of cases and a history of bipolar depressive episode in 60%. Precipitating factors in the form of life events were reported in 53% and included recent marriage (90%), loss of job and property disputes. The mean duration of the untreated episode was 24 weeks; three of the patients had untreated depression lasting for 52 weeks and two others for longer. The mean hospital stay for the sample population was 4 (SD ± 2) weeks.
The core symptoms of a depressive episode, such as depressive thoughts, were present in 86% of the patients, and ideas of self-harm were present in 87%; sadness and loss of interest were reported by approximately twothirds of the sample. Associated symptoms such as crying spells were present in 80%, headaches and pains in 35%, anxiety symptoms in 33% and inability to feel any emotions in 15%. Loss of pleasure was reported in 60%, and significant weight loss in 37% of patients. Agitation was recorded in 30%, and 20% had psychomotor retardation and diurnal variation of mood.
Second- and third-person auditory hallucination were reported by 19%. Other psychotic symptoms, such as delusions of persecution, were present in 14%, and delusions of reference in 10%. Two and eight per cent of the population had delusions of guilt and nihilism, respectively. More than two psychotic symptoms were reported in 13 patients, and five reported more than three psychotic symptoms.
A combination of antipsychotics and antidepressants were prescribed in 56% of the cases, and electroconvulsive therapy was given in 43%.
According to the ICD-10, to diagnose a depressive episode, the core symptoms of depressed mood, loss of interest and enjoyment and reduced energy level, should be present. Severe depression is diagnosed when the above three symptoms are present to a marked and distressing degree. If patients report mood congruent psychotic symptoms, the classificatory system puts them under the label of psychotic depression. The results of the present study indicate that 20–30% of the patients did not have the so-called ‘core’ symptoms of a depressive episode. Only 63% reported sadness and 19% reported second- and third-person auditory hallucinations.
The present study had limitations because of the retrospective design. Long-term prospective studies will throw more light on psychotic depression.