Psychotic Depressive Episodes Research Articles

Genomic Investigation of Remission and Relapse of Psychotic Depression Treated with Sertraline plus Olanzapine: The STOP-PD II Study

Introduction: Little is known regarding genetic factors associated with treatment outcome of psychotic depression. We explored genomic associations of remission and relapse of psychotic depression treated with pharmacotherapy. Methods: Genomic analyses were performed in 171 men and women aged 18–85 years with an episode of psychotic depression who participated in the Study of the Pharmacotherapy of Psychotic Depression II (STOP-PD II). Participants were treated with open-label sertraline plus olanzapine for up to 12 weeks; those who achieved remission or near-remission and maintained it following 8 weeks of stabilization were eligible to participate in a 36-week randomized controlled trial that compared sertraline plus olanzapine with sertraline plus placebo in preventing relapse. Results: There were no genome-wide significant associations with either remission or relapse. However, at a suggestive threshold, SNP rs1026501 (31 kb from SYNPO2) in the whole sample and rs6844137 (within the intronic region of SYNPO2) in the European ancestry subsample were associated with a decreased likelihood of remission. In polygenic risk analyses, participants who had greater improvement after antidepressant treatments showed a higher likelihood of reaching remission. Those who achieved remission and had a higher polygenic risk for Alzheimer’s disease had a significantly decreased likelihood of relapse. Conclusion: Our analyses provide preliminary insights into the genetic architecture of remission and relapse in a well-characterized group of patients with psychotic depression.

Effect of Neutrophil to Lymphocyte ratio on antidepressant treatment response: moderating effect of sex and mediating effect of Hippocampal volumes.

IntroductionIn recent years much focus has been put on the role of immune/inflammatory alterations in affecting Major Depression (MDD) development and antidepressant efficacy. Neutrophil-to-lymphocyte ratio (NLR) is an inexpensive inflammatory marker shown to be elevated in depressed patients, with large population studies reporting this effect only in women. However, its relation to treatment response is much less clear. Reduced hippocampal volumes (HV) are among the few consistent brain structural predictors of poor treatment response, and they have been shown to be influenced by inflammatory status.ObjectivesTo investigate the effect of NLR on treatment response in MDD patients, testing a possible moderating role of sex. To investigate the effect of NLR on HV and test a possible mediating role of the latter in the relation between NLR and treatment response.MethodsOur study was performed on a sample of 120 MDD inpatients suffering from a non psychotic depressive episode (F=78; M=42). Depression severity was assessed via the Hamilton Depression Rating Scale (HDRS), both at admission and discharge; as a measure of treatment response, delta HDRS was calculated subtracting the two scores. NLR was calculated for each subject. Patients underwent 3T MRI acquisition and bilateral HV were estimated.ResultsWe found a significant moderating effect of sex on the relationship between NLR and Delta HDRS (p < 0.001): a negative relation was found in women (p < 0.001) and a positive one in men (p = 0.042). NLR was found to negatively affect left HV in the whole sample (p = 0.027) and in women (p = 0.038). A positive effect on Delta HDRS was found for both left (p = 0.038) and right (p = 0.027) HV. Finally, we found a significant indirect effect of NLR values on Delta HDRS through left HV in women (95% BCa CI [- 0.948, -0.017]); the direct effect of NLR on Delta HDRS also remained significant (p = 0.002).ConclusionsSex was found to moderate the relation between NLR and treatment response. The detrimental effect in women is in line with previous reports linking inflammation to hampered antidepressant effect; the positive one in men is more surprising: however, the only studies to date on the effect of NLR on antidepressant efficacy report a positive effect in patients with psychotic depression. In women we found NLR to affect treatment response partially through its effect on left HV, providing a possible, albeit incomplete, mechanistic explanation of the effect of inflammatory status on antidepressant efficacy.Disclosure of InterestNone Declared

Nowy obraz objawów psychopatologicznych w dobie pandemii COVID-19 na podstawie pierwszego epizodu depresji psychotycznej.

The emerging SARS-CoV-2 pandemic is known to take a toll on both physical and mental health. We present a case of a patient with a first episode of severe depression with COVID-19-related psychotic features. A patient with no history of mental disorders was admitted to the Psychiatric Unit due to the symptoms of severe depressive episode with psychotic features. Progressive deterioration of his mental health, behavior and activity was observed in March of 2020. He was not infected nor exposed to infectious agents but presented delusions about being infected with SARS-CoV-2 and being a source of transmission to other people. He suffered from Hashimoto disease and recently diagnosed lymphoma which further diagnosis was postponed. He was administrated venlafaxine 150 mg and mirtazapine 45 mg with addition of olanzapine up to 20 mg and risperidone up to 6 mg per day. No side effects were reported. The patient reached a full recovery with the exception of slightly blunted ability to feel pleasure, minor problems with concentration and occasional pessimistic thoughts. Discussion: The social distancing recommendations put a psychological strain related to alienation and negative emotions which can favor development of depressive symptoms. Analysis of psychological mechanisms related to the pandemic and restrictions is significant for limiting negative influence of global crisis on individual mental well-being. Conclusions: In this case the impact of global anxiety and its integration into the developing psychopathological symptoms is especially significant. The circumstances surrounding an episode of affective disorder may shape its course and thought content.

Safety and efficacy of Ketamine in a patient with psychotic depression, cardiovascular disease, and starvation risk

Introduction: There has been a rising interest in ketamine as a promising treatment for refractory depression. Despite this, there is uncertain knowledge regarding aspects of the routinary use of ketamine for treating depression, such as optimal doses, long term toxicity, abuse potential in depressed patients, probable adverse effects associated with antidepressant drugs, the indication of ketamine in psychotic patients, and the ethical concerns of ketamine use.
 Clinical case: A 63 year-old woman with a psychotic depressive episode, catatonic features, cardiovascular disease (patent foramen ovale and atrial fibrillation) , and starvation risk because she refused food intake. She was sent to electroconvulsive therapy (ECT) after several weeks of oral administration of benzodiazepine, antipsychotic, and antidepressant medications; the patient presented no improvement, but she was rejected due to her cardiovascular comorbidity. Two IV Ketamine doses were used as a life-saving strategy with good clinical response, mainly in terms of the catatonic features. The ketamine treatment was not only effective but also well tolerated.
 Discussion: Despite the little information regarding its use in psychotic and catatonic patients, this case would suggest that it remains effective and safe, as well as a good option for patients with cardiovascular disease and those who cannot use electroconvulsive therapy.

Factor analysis of the CORE measure of psychomotor disturbance in psychotic depression: Findings from the STOP-PD II study

The CORE instrument is commonly used to measure psychomotor disturbance. We examined the factor structure of the CORE in 266 adults with an acute episode psychotic depression, a disorder with a high rate of psychomotor disturbance. Exploratory factor analysis identified a two-factor solution: Factor 1 corresponded to the CORE's retardation and non-interactiveness items and Factor 2 corresponded to its agitation items. Internal consistency was excellent for Factor 1 but questionable for Factor 2. These findings suggest that the CORE's retardation and non-interactiveness items should be combined in one subscale when assessing patients with an acute episode of psychotic depression.

Electroconvulsive therapy after conservative treatment of vertebral fractures

IntroductionElectroconvulsive therapy (ECT) remains a valuable treatment for major depression with psychotic symptoms. However, it is necessary to pay special attention when there is a history of fractures.ObjectivesThrough the description of the following clinical case, we will emphasize the importance of screening for vertebral fractures within ECT and the different procedures that must be taken if that occurs.MethodsWe undertook a narrative literature review by performing a search on PubMed for English-written articles. The query used was “Electroconvulsive Therapy” AND “Vertebral Fractures”.ResultsA 71-year-old woman was admitted with an episode of psychotic depression. Basic tests were performed and were all normal. After not responding to pharmacologic treatment, she was referred for ECT. The patient had a full recovery after 4 weeks of biweekly sessions. She was discharged and proposed for maintenance ECT. However, she started complaining of back pain after falling and did an X-ray and CT scan which revealed fractured L1 and L2. It was suggested conservative treatment with a Jewett orthosis. Within this period, the ECT was suspended and after a 4-week treatment, the fracture was consolidated. As there was no risk of neurological compression, the treatment was restarted with the same dosage of succinylcholine, and it was achieved complete muscular relaxation. The patient fully recovered without any orthopedic sequel.ConclusionsElectroconvulsive therapy can be safely performed after conservative treatment of vertebral fractures, if special attention is provided to complete muscular relaxation. For this effect, the dosage of succinylcholine can be adjusted.DisclosureNo significant relationships.

Association between psychomotor disturbance and treatment outcome in psychotic depression: a STOP-PD II report.

Little is known about the relationship between psychomotor disturbance (PMD) and treatment outcome of psychotic depression. This study examined the association between PMD and subsequent remission and relapse of treated psychotic depression. Two hundred and sixty-nine men and women aged 18-85 years with an episode of psychotic depression were treated with open-label sertraline plus olanzapine for up to 12 weeks. Participants who remained in remission or near-remission following an 8-week stabilization phase were eligible to participate in a 36-week randomized controlled trial (RCT) that compared the efficacy and tolerability of sertraline plus olanzapine (n = 64) with sertraline plus placebo (n = 62). PMD was measured with the psychiatrist-rated sign-based CORE at acute phase baseline and at RCT baseline. Spearman's correlations and logistic regression analyses were used to analyze the association between CORE total score at acute phase baseline and remission/near-remission and CORE total score at RCT baseline and relapse. Higher CORE total score at acute phase baseline was associated with lower frequency of remission/near-remission. Higher CORE total score at RCT baseline was associated with higher frequency of relapse, in the RCT sample as a whole, as well as in each of the two randomized groups. PMD is associated with poorer outcome of psychotic depression treated with sertraline plus olanzapine. Future research needs to examine the neurobiology of PMD in psychotic depression in relation to treatment outcome.

Effect of Older vs Younger Age on Anthropometric and Metabolic Variables During Treatment of Psychotic Depression With Sertraline Plus Olanzapine: The STOP-PD II Study

To examine the effect of older versus younger age on change in anthropometric and metabolic measures during extended treatment of psychotic depression with sertraline plus olanzapine. Two hundred and sixty-nine men and women aged 18-85 years with an episode of psychotic depression were treated with open-label sertraline plus olanzapine for up to 12 weeks. Participants who remained in remission following an 8-week stabilization phase were eligible to participate in a 36-week randomized controlled trial (RCT) that compared the efficacy and tolerability of sertraline plus olanzapine with sertraline plus placebo. Weight, waist circumference and plasma lipids, glucose, HbA1c, and insulin were measured at regular intervals during the acute, stabilization and randomized phases of the study. Linear mixed models were used to analyze the trajectories of anthropometric and metabolic measures. Participants aged 60 years or older experienced less weight gain and less increase in cholesterol during the combined acute and stabilization phases of the study compared with those aged 18-59 years. At the acute-stabilization termination visit, mean weight in older participants was 6.5 lb. less than premorbid weight, whereas it was 17.9 lb. more than premorbid weight in younger participants. In the RCT, there was a significant interaction of treatment and age group for the trajectory of weight, but the post hoc tests that compared age groups within each treatment arm were not statistically significant. There were no clinically significant differences between younger and older participants in glycemic measures. Older patients with psychotic depression experienced less increase in weight and total cholesterol than their younger counterparts during acute and stabilization treatment with sertraline plus olanzapine. In the older group, weight gained during the acute and stabilization phases appeared to be partial restoration of weight lost during the index episode of depression, whereas weight gain in younger participants was not.

Effect of Continuing Olanzapine vs Placebo on Relapse Among Patients With Psychotic Depression in Remission

Psychotic depression is a severely disabling and potentially lethal disorder. Little is known about the efficacy and tolerability of continuing antipsychotic medication for patients with psychotic depression in remission. To determine the clinical effects of continuing antipsychotic medication once an episode of psychotic depression has responded to combination treatment with an antidepressant and antipsychotic agent. Thirty-six week randomized clinical trial conducted at 4 academic medical centers. Patients aged 18 years or older had an episode of psychotic depression acutely treated with sertraline plus olanzapine for up to 12 weeks and met criteria for remission of psychosis and remission or near-remission of depressive symptoms for 8 weeks before entering the clinical trial. The study was conducted from November 2011 to June 2017, and the final date of follow-up was June 13, 2017. Participants were randomized either to continue olanzapine (n = 64) or switch from olanzapine to placebo (n = 62). All participants continued sertraline. The primary outcome was risk of relapse. Main secondary outcomes were change in weight, waist circumference, lipids, serum glucose, and hemoglobin A1c (HbA1c). Among 126 participants who were randomized (mean [SD] age, 55.3 years [14.9 years]; 78 women [61.9%]), 114 (90.5%) completed the trial. At the time of randomization, the median dosage of sertraline was 150 mg/d (interquartile range [IQR], 150-200 mg/d) and the median dosage of olanzapine was 15 mg/d (IQR, 10-20 mg/d). Thirteen participants (20.3%) randomized to olanzapine and 34 (54.8%) to placebo experienced a relapse (hazard ratio, 0.25; 95% CI, 0.13 to 0.48; P < .001). The effect of olanzapine on the daily rate of anthropometric and metabolic measures significantly differed from placebo for weight (0.13 lb; 95% CI, 0.11 to 0.15), waist circumference (0.009 inches; 95% CI, 0.004 to 0.014), and total cholesterol (0.29 mg/dL; 95% CI, 0.13 to 0.45) but was not significantly different for low-density lipoprotein cholesterol (0.04 mg/dL; 95% CI, -0.01 to 0.10), high-density lipoprotein cholesterol (-0.01 mg/dL; 95% CI, -0.03 to 0.01), triglyceride (-0.153 mg/dL; 95% CI, -0.306 to 0.004), glucose (-0.02 mg/dL; 95% CI, -0.12 to 0.08), or HbA1c levels (-0.0002 mg/dL; 95% CI, -0.0021 to 0.0016). Among patients with psychotic depression in remission, continuing sertraline plus olanzapine compared with sertraline plus placebo reduced the risk of relapse over 36 weeks. This benefit needs to be balanced against potential adverse effects of olanzapine, including weight gain. ClinicalTrials.gov Identifier: NCT01427608.

S236. IS MAINTENANCE TREATMENT NEEDED WHEN THE FIRST EPISODE OF PSYCHOSIS IS NOT DUE TO SCHIZOPHRENIA?

BackgroundDebate continues about how long maintenance treatment should be continued following a first episode of psychosis (FEP). Resolving this question requires an understanding of the risk of recurrence which would be expected to vary as a function of the underlying cause of the psychosis. The range of diagnoses that may present as a FEP include schizophrenia and related schizophrenia spectrum disorders, bipolar mania, bipolar and unipolar depression, substance-induced psychosis, and unspecified psychotic disorders. The majority of FEP patients will receive the diagnosis of schizophrenia or bipolar disorder for which the 1- year risk of illness recurrence is estimated at 77% and 41%, respectively. We reviewed the literature in order to estimate the risk of relapse and the risk of developing a primary psychotic disorder following a FEP due to other diagnoses.MethodsWe conducted a primary literature review using Medline and PubMed. We included the following search terms: first episode, relapse, recurrence, depression with psychosis, psychotic depression, mania with psychosis, substance induced psychosis and psychosis. We included prospective and retrospective studies including those that involved medication discontinuation or naturalistic follow-up to determine the risk of recurrence following a FEP. We also reviewed the literature to determine the likelihood that FEP with these diagnoses would transition to a primary psychotic disorder (schizophrenia spectrum disorder or major mood disorder) for which published rates of recurrence would apply.ResultsTwo studies were identified which reported on the recurrence rate following a first episode of psychotic depression. Recurrence rates ranged from 27% at eight months to 80.6% at a mean of 32 months. An additional study found that following a first episode of psychotic depression, 29.9% and 14.3% of patients were diagnosed with schizophrenia and bipolar disorder, respectively, at 10-year follow-up. The risk of developing a primary psychotic disorder following a first episode of substance-induced psychosis has been investigated in three studies which reported rates of conversion to a primary psychotic disorder of 25% at one year, 25% at 10 years and 32% at 20 years. The risk of developing a primary psychotic disorder following a cannabis-induced psychosis has been investigated in three studies which reported rates of conversion of 44.5% at three years, 46% at eight years, and 47.4% at 20 years. Patients with a first episode of unspecified psychosis have been reported in a single study to have a 73.7% risk of developing a primary psychotic disorder at 10 year follow-up.DiscussionThe risk of illness recurrence following a FEP not initially diagnosed as a schizophrenia spectrum or bipolar disorder was found to vary by both initial diagnosis and by follow-up duration. Psychotic depression, substance-induced psychosis and other unspecified psychoses were all associated with either substantial risks of illness recurrence or development of a primary psychotic disorder. The risk of illness recurrence following medication discontinuation has not been established for these disorders as many of these studies included patients whether they were on or off of their prescribed medications. Clinical recommendation should be informed by future research on recurrence rates with and without maintenance medication for the different causes of FEP. In the meantime, patients with a FEP and their family members should be fully informed about the risk of illness recurrence and development of a primary psychotic disorder when considering any trial of medication discontinuation.

Psychotic depression: How to diagnose this often undetected — and hidden — condition

Major depressive disorder with psychotic features, commonly referred to as psychotic depression, is a diagnosis that often goes undetected in children, adolescents, and adults alike. One of the most challenging aspects of this disorder is that the patient's delusional pattern of thinking can be subtle in nature, increasing the likelihood that the underlying psychotic component to their presentation will be overlooked by even the most skilled clinicians. Moreover, studies have shown that once patients have been successfully treated for an episode of psychotic depression, they often reflect back to their illness and express having felt reluctance to reveal the extent of the paranoia and delusions they were experiencing due to fear of being labeled as “crazy,” adding an additional degree of difficulty in diagnosing and, ultimately, treating that patient.

Psychotic Depression and Suicidal Behavior

Objective: This study investigated how severely depressed individuals experienced the relationship between psychotic symptoms and suicidal ideation and behavior. Method: Semi-structured qualitative interviews were conducted with a purposive sample of nine inpatients from a psychiatric university hospital between September 2012 and May 2013 fulfilling diagnostic criteria for a psychotic depressive episode as part of a unipolar or bipolar disorder. Analysis was conducted using systematic text condensation. Results: Participants experienced (1) being directed to perform impulsive potentially fatal actions, (2) feeling hounded to death, (3) becoming trapped in an inescapable darkness, and (4) being left bereft of mental control. They described how impulsivity directed by delusions and hallucinations resulted in unpredictable actions with only moments from decision to conduct. Suicide was seen as an escape not only from life problems but also from psychotic experiences and intense anxiety. Participants reported being in a chaotic state, unable to think rationally or anticipate the consequences of their actions. Their ability to identify and communicate psychotic symptoms and suicidal ideation and behavior was compromised, leaving them to struggle alone with these terrifying experiences. Conclusions: Suicide risk assessments based on verbal reports from individuals with psychotic depression may not always be valid due to potential impulsivity and underreporting of suicidal ideation. It may be important for clinicians to explore the delusional content of such patients’ experiences to assess the possibility of suicide as a result of shame, guilt, remorse, or altruistic intentions to save others from harm.

Syndrome of inappropriate antidiuretic hormone secretion associated with desvenlafaxine

IntroductionDesvenlafaxine is a prescription medication approved for the treatment of major depressive disorder in adults. Hyponatremia secondary to inappropriate secretion of antidiuretic hormone (SIADH) is a possible side effect in patients receiving serotonin-norepinephrine reuptake inhibitors (SNRIS)MethodTo report a case of SIADH associated with desvenlafaxine.ResultsWe present a 80-year-old female patient who required hospitalization due to an episode of psychotic depression. During the hospitalization, the patient developed hyponatremia after commencing treatment with desvenlafaxine. The serum sodium at this time was 117 mmol/L, serum osmolality was 249 mosmol/kg, urine osmolality 395 mosmol/kg and urine sodium 160 mmol/L, consistent with a diagnosis of SIADH. Desvenlafaxine was ceased and fluid restriction implemented. The mental status improved, and electrolyte studies 6 days later revealed serum sodium and osmolality values of 135 mEq/L during treatment with duoxetine.ConclusionsSIADH has been reported with a range of antidepressants in elderly patients. This case report suggests that desvenlafaxine might cause clinically significant hyponatremia. Close monitoring is recommended in patients starting therapy with antidepressant treatment to study and prevent possible adverse effects.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Catatonia in Psychotic Depression Associated With Bereavement

To the Editor: In the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), catatonia is not recognized as a separate disorder but is associated with many psychiatric and medical conditions.1 Psychiatric causes of catatonia range from 70% to 80%, and organic causes of catatonia range from 20% to 30%.2 Among the psychiatric causes of catatonia, around 30% are related to mood disorders, and approximately 10% to 15% are associated with schizophrenia.2 Catatonia is a rare condition for someone to experience with a major depressive episode with psychotic features. There is only 1 report describing a young woman with this rare phenomenon during the postpartum period.3 Otherwise, catatonia associated with bereavement has rarely been described. There are only 2 reports describing terminal cancer patients who developed brief psychotic disorder with catatonic syndromes after bereavement.4,5 Here, we report the case of a patient who developed an emergent catatonia in a major depressive episode with psychotic features associated with bereavement. The catatonia was improved by injectable diazepam and olanzapine. The psychotic depression was successively treated with mirtazapine and olanzapine. Case report. Ms A is a 42-year-old woman without psychiatric illness history. Her fiance’s sudden death during a gastric operation was a terrible shock to her. After he died, Ms A was sad and anhedonic, with guilty delusion and suicidal ideation. She presented with intense negativism about herself and severe psychomotor retardation. She was unable to carry out daily activities without help at home and was admitted to the hospital. During hospitalization, she was mute, presented extreme loss of motor skill, held rigid poses for hours, and was not responding to any external stimuli. She required intensive nursing care and administration of intravenous fluids for nutrition and carried a urethral catheter for bladder distention. A series of examinations were arranged. The results of blood counts and serum chemistry were within normal limits. Her brain computerized tomography was normal. Drug screening tests were negative for central nervous system suppressants. After full diagnostic workup, Ms A was administered injectable diazepam 20 mg/d combined with olanzapine 10 mg/d. On the 10th day of hospitalization, the catatonia resolved gradually. While recovering from catatonia, Ms A presented with severe depression and guilty delusion (according to DSM-5 criteria). Treatment with tablet mirtazapine 60 mg/d and olanzapine 10 mg/d resulted in gradual improvement of her psychotic depression. According to the DSM-5,1 Ms A experienced a major depressive episode with psychotic features just after her fiance died. A period of catatonia developed insidiously during this psychotic depressive episode. A previous report described catatonia that developed during a major depressive episode with psychotic features in the postpartum period.3 The case of Ms A suggests that patients may develop catatonia in psychotic depression when they experience loss of close relatives. Based on clinical evidence, the 2 main treatment options for catatonic depression are benzodiazepines and electroconvulsive therapy.6 Atypical antipsychotics are also utilized in certain cases, as they are thought to help manage psychotic symptoms or to be an augmentation strategy for depression.6 As in our case, injectable diazepam and olanzapine demonstrate their efficacy in treating this condition. Psychotic depression affects approximately 25% of patients who are admitted to the hospital for depression.7 Usually, combinations of antidepressants and antipsychotic medications are needed to treat this condition.8 In the case of Ms A, mirtazapine combined with olanzapine demonstrated efficacy in treating catatonia. To our knowledge, no hypotheses have been made linking the neurobiology of psychotic depression and that of catatonic syndromes. Our case, as well as the case reported during the postpartum period,3 highlight the need for clinicians to watch for the emergence of catatonia in cases of psychotic depression, especially during the postpartum and bereavement periods.

Strictly come therapy

‘Since 2000, I have suffered three episodes of psychotic depression. On each occasion, I danced myself back to health. The care I received has been good, but it is the dancing that has lifted me and grounded me. I believe I became ill because I lived a life that was not true to myself.’

Demographic and clinical differences between early- and late-onset major depressions in thirteen psychiatric institutions in China

BackgroundLittle is known about the demographic and clinical differences between early- and late-onset depressions (EOD and LOD, respectively) in Chinese patients. This study examined the demographic and clinical profile of EOD (<=25 years) compared to LOD (>25 years) in China. MethodsA consecutively recruited sample of 1178 patients with MDD was assessed in 13 psychiatric hospitals or psychiatric units of general hospitals in China nationwide. The cross-sectional data of patients׳ demographic and clinical characteristics and prescriptions of psychotropic drugs including antidepressants, mood stabilizers, antipsychotics and benzodiazepines were recorded using a standardized protocol and data collection procedure. ResultsTwo hundred and seventy five (23.3%) of the 1178 patients fulfilled criteria for EOD. In multiple logistic regression analyses, compared to LOD patients their EOD counterparts were more likely to be unmarried and unemployed, had more atypical and psychotic depressive episodes, had bipolar features, while they had more lifetime depressive episodes. ConclusionsThe demographic and more severe clinical features of EOD in Chinese patients were basically consistent with those found in Western populations. The association between socio-cultural factors and development of EOD warrants further studies.

Persistent delusional theme over 13 episodes of psychotic depression

Unipolar psychotic depression (PD) is a highly debilitating condition, which needs intense monitoring and treatment. Among patients with recurrent PD, delusions tend to be very similar or identical over several separate episodes during the course of illness, but case-reports illustrating this clinical phenomenon in detail are lacking from the literature. Case report describing the 45-year-old Ms. J, who has experienced multiple episodes of PD. The report is based on a review of her medical file. The delusional theme of Ms. J's initial episode of PD reappeared at several subsequent episodes. During the majority of admissions, Ms. J was treated with electroconvulsive therapy, which resulted in significant improvement in the depressive, psychotic and catatonic features. Ms. J's case illustrates that PD can be a stable phenotype over many episodes and that it is important to recognize psychotic symptoms in order to prescribe the best possible treatment.

Challenges in the Treatment of Major Depressive Disorder With Psychotic Features

Psychotic depression is associated with significant morbidity and mortality but is underdiagnosed and undertreated. In recent years, there have been several studies that have increased our knowledge regarding the optimal treatment of patients with psychotic depression. The combination of an antidepressant and antipsychotic is significantly more effective than either antidepressant monotherapy or antipsychotic monotherapy for the acute treatment of psychotic depression. Most treatment guidelines recommend either the combination of an antidepressant with an antipsychotic or ECT for the treatment of an acute episode of unipolar psychotic depression. The optimal maintenance treatment after a person responds to either the antidepressant/antipsychotic combination or the ECT is unclear particularly as it pertains to length of time the patient needs to take the antipsychotic medication. Little is known regarding the optimal treatment of a patient with bipolar disorder who has an episode of psychotic depression or the clinical characteristics of responders to medication treatments vs ECT treatments.

Characteristics, treatments and outcome of psychosis in Thai SLE patients

ObjectivesTo study the clinical characteristics and outcomes of psychosis and its clinical correlation with disease activity in Thai systemic lupus erythematosus (SLE) patients. MethodsFrom 750 SLE patients, 36 episodes of psychosis or psychotic depression in SLE patients were retrospectively identified between June 1999 and June 2009 at Srinagarind Hospital, Khon Kaen University. The clinical characteristics, laboratory analyses, disease activity, treatments and outcomes were studied. ResultsA total of 35 SLE patients had 36 psychotic episodes that consisted of 29 psychotic episodes and 7 psychotic depressive episodes. Eleven episodes (30.6%) occurred during the first manifestation of lupus. Psychotic symptoms included persecutory delusion (50%), bizarre delusion (44.4%), third person auditory hallucinations (44.4%) and visual hallucinations (36.1%). Twenty four episodes (67%) were associated with active lupus in CNS and other organs. All patients received immunotherapy and psychotropic treatments. Psychosis and depressive psychosis were treated with antipsychotics and antidepressants for a mean duration of 71 and 410days. One death resulted from suicide, and one of thirty four cases (2.9%) had a reoccurrence within a mean follow-up period of 44months. ConclusionAbout one-third of the psychotic episodes occurred during the first manifestation of lupus. Persecutory delusion, bizarre delusion, third person auditory hallucination, and visual hallucination were common. During psychotic episodes, lupus activity was active in other parts of CNS and organs in 67% of patients. Depressive psychosis required psychotropic treatment longer than psychosis alone. The psychiatric outcome was very favorable. Most of psychotic episodes (97.1%) were fully remitted and rarely showing recurrences.

A Patient with an Implanted Cardiac Defibrillator Not Deactivated During Acute and Maintenance Electroconvulsive Therapy

Electroconvulsive therapy (ECT) has been shown to be a safe and effective treatment for severe or medication-resistant depressive patients. 1 Although absolute contraindications no longer exist for its use, 1 patients with cardiac rhythm management devices, such as implantable cardioverter defibrillators (ICD), might represent a challenge when ECT is considered as a treatment option. ICDs have been used for more than 20 years in patients at high risk of sudden death due to ventricular arrhythmias. 2 An ICD is a device that monitors rhythm and heart rate, detects tachyarrhythmias and generates an electrical impulse to terminate them. The data generated are recorded and can be retrieved by ICD interrogation with an external programmer later on. This subgroup of patients is by no means negligible in daily psychiatric practice, as in recent years the number of ICD carriers is increasing. 3 In this context, we report the case of a 65-year-old man with recurrent Major Depressive Disorder (MDD) who had an ICD implanted and who received a course of ECT for the treatment of a psychotic depressive episode. His ICD was initially deactivated, then not deactivated, and finally he continued to receive maintenance ECT with the device activated, for a total of 70 sessions. To our knowledge, there is only one prior report of the use of ECT with an activated ICD. A 62-year-old man had his device activated while receiving ECT, under the premise of treating potential lethal arrhythmias. 4 The present case will be the first to report a sequence of acute and maintenance ECT treatment with an activated ICD and a successful outcome.