Psychotic Major Depression Patients Research Articles

The influence of gender-specific factors influencing severe anxiety in psychotic major depression: role of thyroid hormones and depression severity.

Psychotic major depression (PMD) is characterized by major depressive disorder (MDD) accompanied by delusions or hallucinations. While the prevalence of PMD and its association with anxiety have been studied, gender-specific differences and the role of thyroid hormones in PMD-related anxiety remain less explored. A total of 1718 first-episode and drug-naïve MDD patients was assessed for the presence of PMD and severe anxiety. Clinical assessments, including Hamilton Depression Rating Scale (HAMD), Hamilton Anxiety Rating Scale (HAMA), Positive and Negative Syndrome Scale (PANSS), and Clinical Global Impressions-Severity (CGI-S) scale, were conducted to assess depression, anxiety, psychotic symptoms, and clinical severity, respectively. Blood samples were collected to measure thyroid function parameters. The prevalence of severe anxiety was higher in PMD patients compared to non-psychotic MDD patients (71.3% vs. 5.3%). No significant gender differences were observed in the prevalence of severe anxiety among PMD patients. However, elevated thyroid-stimulating hormone (TSH) levels and increased depression severity (HAMD scores) were identified as independent risk factors for severe anxiety in female PMD patients. In contrast, no significant risk factors were found in male PMD patients. The area under the receiver operating characteristic (AUCROC) analysis revealed that the HAMD score and TSH level showed acceptable discriminatory capacity for distinguishing between female PMD patients with and without severe anxiety. This study highlights the heightened prevalence of severe anxiety in PMD patients, with TSH levels and depression severity emerging as gender-specific risk factors for anxiety in females. These findings suggest the importance of thyroid hormone assessment and tailored interventions for managing anxiety in female PMD patients.

Prevalence and related factors of anxiety in first episode and drug naïve Chinese Han outpatients with psychotic major depression

BackgroundAnxiety frequently occurs with major depressive disorder (MDD) but to a different extent in the various subtypes. Psychotic major depression (PMD) is a severe subtype of MDD that is under-identified and under-studied. We investigated the prevalence and related risk factors of anxiety in PMD patients. MethodsA total of 1718 first episode and drug naïve MDD patients were recruited. Measures included the Hamilton Depression Scale (HAMD), Clinical Global Impression-Severity scale (CGI-S), Hamilton Anxiety Scale (HAMA), and positive symptom scale of the Positive and Negative Syndrome Scale (PANSS), thyroid hormone levels, and metabolic parameters. Results171 of the entire MDD study sample met the criteria for the PMD subtype. The prevalence of severe anxiety was much higher in PMD patients (22.8 %) than in non-PMD patients (0.4 %) (χ2 = 294.69, P < 0.001, OR = 75.88, 95 % CI = 31.55–182.52). Compared to PMD patients without severe anxiety, PMD patients with severe anxiety had higher HAMD score, CGI-S score, positive symptom subscale score, suicide attempts, blood pressure, thyroid-stimulating hormone (TSH), anti-thyroglobulin (TgAb), and thyroid peroxidases antibody (TPOAb) levels. Furthermore, logistic regression analysis indicated that HAMD score and TSH levels were associated with severe anxiety in PMD patients. LimitationsOur cross-sectional study cannot explain the causal relationship between anxiety severity and risk factors in PMD patients. ConclusionsOur results suggest that PMD patients are more likely to experience severe anxiety than non-PMD patients. The severity of depression and TSH levels are independent risk factors for anxiety in PMD patients.

P.0694 Pharmacological approach to psychotic depression: a retrospective study of antidepressant and antipsychotic use in a psychiatry ward

Recent data suggests that psychotic major depression (PMD) may be a discrete disorder distinguishable from nonpsychotic major depression (NPMD), and that patients with PMD may be more similar to individuals with schizophrenia than individuals with NPMD. The insula is a brain region in which morphometric changes have been associated with psychotic symptom severity in schizophrenia and affective psychosis. It was hypothesized that insular volumes would be reduced in PMD compared to NPMD and controls, and insular volumes would correlate with psychosis but not depression severity. Insular gray matter volumes were measured in PMD and NPMD patients and matched healthy controls using magnetic resonance images and manual morphometry. Clinical measures of illness severity were obtained to determine their relationship with insular volume. Posterior insular volumes were significantly reduced in PMD compared to HC. There were also significant group-by-gender interactions for total, anterior and posterior insular volumes. Using Pearson product-moment correlations, anterior insular volumes did not correlate with depression severity. Left anterior insular volume was significantly correlated with total and positive symptom psychosis severity in the PMD group. Atypical insular morphometry may be related to the inability to distinguish between internally and externally generated sensory inputs characteristic of psychosis.

Prevalence and related factors of suicide attempts in first-episode and untreated Chinese Han outpatients with psychotic major depression

BackgroundMajor depressive depression (MDD) is often accompanied by suicidal behavior. Increasing evidence shows that MDD patients display psychotic symptoms. However, the relationship between psychotic symptoms and suicide attempt in MDD has not been reported. Therefore, this study was to identify the prevalence and associated factors of suicide attempts in first-episode and untreated Chinese Han outpatients comorbid with psychotic major depression (PMD). Methods1718 first-episode and untreated MDD outpatients were assessed with Positive Symptom Scale of Positive and Negative Syndrome Scale (PANSS), the 17-item Hamilton Depression Scale, Hamilton Anxiety Scale, and clinical global impression of severity scale (CGI-S). Some glycolipid metabolism and thyroid hormone parameters were measured. ResultsIn MDD patients, the percentage of PMD was 10.0%. The incidence of attempted suicide in PMD patients was 51.5%, which was more than 3 times higher than that in non-PMD patients (16.7%). In PMD patients, compared to non-attempters, suicide attempters were older, had a longer course of disease, scored higher on all scales, as well as had higher levels of thyroid stimulating hormone (TSH), thyroid peroxidases antibody, anti-thyroglobulin and blood glucose. PANSS positive symptom, CGI, diastolic blood pressure and TSH were independently associated with suicide attempts of PMD. ConclusionsPMD patients have a higher prevalence of suicide attempt than non-PMD patients. Some demographic and clinical parameters are relevant factors for suicide attempt in PMD patients.

Guilt Delusional Beliefs Increase the Risk of Suicidal Attempt in Elderly Unipolar Psychotic Depressives.

The aim of this study was to investigate the differential effect of various delusion categories, namely, guilt, paranoid, impending disaster, and somatic on suicidal attempts in elderly patients experiencing unipolar psychotic major depression (PMD), because the evidence on this is scarce. The sample consisted of 65 consecutively admitted patients 60 years or older, experiencing PMD, and assessed by means of Structured Clinical Interview for DSM-4 (Patient Edition), Hamilton Depression Rating Scale, Mini-Mental Status Examination (MMSE), and by a physical impairment rating scale. Patients with guilt delusional beliefs had 5.31 times higher odds (95% confidence interval, 1.37-25.40) of a suicidal attempt than the patients without guilt delusional beliefs, controlling for sex, age, prior history of suicide attempt, MMSE, and hallucinations. In addition, 17 PMD patients with lifetime suicidal attempt compared with 48 PMD patients without lifetime suicidal attempt presented only higher age of disorder onset (p = 0.008). Of the four categories of delusions assessed, only guilt delusions were associated with an increased risk for suicidal attempt.

P261 Clinical outcomes of high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) and electroconvulsive therapy (ECT) in the treatment of major depression. An overview of findings from meta-analyses

Background Meta-analyses comparing the short-term clinical outcomes of high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) and electroconvulsive therapy (ECT) in major depression produced conflicting results. The aim of the current study was to summarise the results of these meta-analyses. Methods A systematic literature search of PubMed and PsycInfo (any time – 13.01.2016) identified k = 4 systematic reviews (published in 2010–2014) comparing the clinical outcomes of ECT and HF-rTMS in major depression using quantitative meta-analysis. The short-term outcomes were the standardised mean change scores (baseline – last stimulation) on depression scales and odds or risk ratios of response, remission, and acceptability (dropout) rates. Since different meta-analytical approaches were used, we have pooled the effects using random-effects model with inverse-variance weights based on data shown in reviews. Results The k = 4 reviews included different combinations of k = 8 open-label or single-blind, randomised primary studies with major depression patients. Most studies utilised right unilateral ECT (2.5 times the seizure threshold, 6–12 sessions) and HF-rTMS (10–20 Hz) of the left dorsolateral prefrontal cortex (90–110% of the resting motor threshold, 10–20 sessions). The pooled weighted effects favoured ECT over HF-rTMS in terms of reduction in depression severity (change scores in k = 2 reviews), while response and acceptability rates of both methods were similar (in k = 2 and k = 3 reviews respectively), and remission rates were inconsistent in k = 3 reviews (possibly due to heterogeneous definitions of remission). The individual study effect sizes favoured ECT over HF-rTMS in terms of reduction in depression severity and remission rate in studies with psychotic major depression patients. Conclusion Uniform meta-analytical approaches suggest that ECT might be clinically superior to HF-rTMS in psychotic major depression, while the clinical outcomes tend to be similar in non-psychotic major depression in the short-term treatment. Future blinded randomised trials are required to compare the long-term clinical outcomes of both methods in clinically-homogeneous samples with major depression.

Ten-year outcomes in first episode psychotic major depression patients compared with schizophrenia and bipolar patients

We aimed to investigate long-term outcomes in psychotic major depression patients compared to schizophrenia and bipolar/manic psychosis patients, in an incidence sample, while accounting for diagnostic change.Based on Aetiology and Ethnicity in Schizophrenia and Other Psychoses (ÆSOP and ÆSOP-10), a first episode psychosis cohort was followed-up 10years after first presentation. The Schedules for Clinical Assessment in Neuropsychiatry, WHO Life Chart and Global Assessment of Functioning were used to assess clinical, social and service use outcomes.Seventy-two PMD patients, 218 schizophrenia patients and 70 psychotic bipolar disorder/mania patients were identified at baseline. Differences in outcome between PMD and bipolar patients based on baseline and lifetime diagnosis were minimal. Differences in clinical, social and service use outcomes between PMD and schizophrenia were more substantial with PMD patients showing better outcomes on most variables. However, there was some weak evidence (albeit not quite statistically significant at p<0.05) based on lifetime diagnoses that PMD patients were more likely to attempt suicide (OR 2.31, CI 0.98–5.42, p0.055) and self-harm (OR 2.34, CI 0.97–5.68, p0.060).PMD patients have better social and service use outcomes compared to people with schizophrenia, but may be more likely to attempt suicide or self-harm. This unique profile is important for clinicians to consider in any risk assessment.

C-20 * Examining the Effects of Negative Psychotic Symptoms and Cortisol Levels on Verbal Memory in Psychotic Major Depression

Objective: This study examined the interactions between cortisol levels and negative symptoms (i.e., blunted affect, psychomotor retardation, and emotional withdrawal) of psychotic major depression (PMD) on verbal memory, after controlling for depression. Method: Archival data were used from the Hypothalamic-Pituitary-Adrenal (HPA) Axis Study. Forty-five PMD patients completed measures that included the Hamilton Depression Rating Scale (HDRS), Brief Psychotic Rating Scale (BPRS), and the California Verbal Learning Scale – II (CVLT-II). Results: Hierarchical regressions were conducted for verbal memory with cortisol and negative psychotic symptoms as predictors, after controlling for depression. Negative psychotic symptoms were a significant predictor of learning (CVLT-II Trials 1−5; r2 = 0.151, p < 0.05) and delayed memory (CVLT-II Long Delayed Free Recall; r2 = 0.154, p < 0.05) abilities. Insignificant results were noted between the individual predictors and verbal recognition memory and for the interactions between cortisol and negative symptoms on verbal memory (p > 0.05). Conclusion(s): The results indicate that negative psychotic symptoms uniquely predict verbal memory, specifically learning and delayed memory, independent of depression severity in PMD patients. Clinically, the findings suggest that negative symptoms may be an important factor to consider for treatment to help PMD patients cognitively perform in their daily lives.

Stability of cognition across wakefulness and dreams in psychotic major depression

Cognitive bizarreness has been shown to be equally elevated in the dream and waking mentation of acutely symptomatic inpatients diagnosed with affective and non-affective psychoses. Although some studies have reported on dream content in non-psychotic depression, no study has previously measured this formal aspect of cognition in patients hospitalized for Psychotic Major Depression (PMD). Sixty-five dreams and 154 waking fantasy reports were collected from 11 PMD inpatients and 11 age- and sex-matched healthy controls. All narrative reports were scored by judges blind to diagnosis in terms of formal aspects of cognition (Bizarreness). Dream content was also scored (Hall/Van de Castle scoring system).Unlike controls, PMD patients had similar levels of cognitive bizarreness in their dream and waking mentation. Dreams of PMD patients also differed from those of controls in terms of content variables. In particular, Happiness, Apprehension and Dynamism were found to differ between the two groups. Whereas dream content reflects a sharp discontinuity with the depressive state, cognitive bizarreness adequately measures the stability of cognition across dreams and wakefulness in PMD inpatients.

Insular cortex abnormalities in psychotic major depression: Relationship to gender and psychotic symptoms

Recent data suggests that psychotic major depression (PMD) may be a discrete disorder distinguishable from nonpsychotic major depression (NPMD), and that patients with PMD may be more similar to individuals with schizophrenia than individuals with NPMD. The insula is a brain region in which morphometric changes have been associated with psychotic symptom severity in schizophrenia and affective psychosis. It was hypothesized that insular volumes would be reduced in PMD compared to NPMD and controls, and insular volumes would correlate with psychosis but not depression severity. Insular gray matter volumes were measured in PMD and NPMD patients and matched healthy controls using magnetic resonance images and manual morphometry. Clinical measures of illness severity were obtained to determine their relationship with insular volume. Posterior insular volumes were significantly reduced in PMD compared to HC. There were also significant group-by-gender interactions for total, anterior and posterior insular volumes. Using Pearson product-moment correlations, anterior insular volumes did not correlate with depression severity. Left anterior insular volume was significantly correlated with total and positive symptom psychosis severity in the PMD group. Atypical insular morphometry may be related to the inability to distinguish between internally and externally generated sensory inputs characteristic of psychosis.

Clinical correlates of age of onset in psychotic depression

The issue whether the clinical characteristics of unipolar psychotic major depression (PMD) vary according to the age of onset remains still unclear. Thus, the aim of this study was to assess comparatively a broad set of clinical characteristics of three groups of PMD patients, namely young early-onset ( n = 30), elderly early-onset ( n = 34) and elderly late-onset ( n = 35). Ninety-nine inpatients suffering from DSM-IV unipolar PMD were assessed on the basis of Structured Clinical Interview for DSM-IV (SCID-IV), Hamilton Rating Scale for Depression (HRSD) and a physical impairment rating scale. The elderly late-onset patients suffered from overall more severe depression compared to both early-onset ones, more psychic anxiety compared to elderly early-onset patients and more gastrointestinal symptoms compared to young early-onset patients. Additionally, they expressed significantly more frequently delusions of somatic content and higher scores on the HRSD item of hypochondriasis than their young early-onset counterparts. The group of elderly early-onset PMD patients was found to hold an intermediate position between the young early-onset and elderly late-onset PMD patients with regard to hypochondriacal ideation, gastrointestinal symptoms and delusions of somatic, guilt, and paranoid content. Their stability of delusional content across successive episodes was found to extend into old age. Nevertheless, they expressed additional somatic delusions. Overall, the findings of the present study suggest considerable differences between young early-onset, elderly early-onset and elderly late-onset PMD patients with respect to their clinical features.

P01-41 - Age of onset in psychotic unipolar depression: a comparative clinical study

ObjectiveThe issue whether the clinical characteristics of unipolar psychotic major depression (PMD) vary according to the age of onset remains still unclear. In this study we assess comparatively the clinical characteristics of young early-onset (n=30), elderly early-onset (n=34) and elderly late-onset (n=35) psychotic depressives.MethodsNinety-nine inpatients suffering from DSM IV unipolar PMD were assessed on the basis of SCID IV, HRSD and a physical impairment rating scale.ResultsThe elderly late-onset patients suffered from overall more severe depression compared to both categories of early-onset ones, more gastrointestinal symptoms compared to young early-onset patients and more psychic anxiety compared to elderly early-onset patients. Moreover, they expressed significantly more frequently delusions of somatic content and had higher scores on the HRSD item of hypochondriasis than their young early-onset counterparts. The group of elderly early-onset PMD patients was found to hold an intermediate position between the young early-onset and elderly late-onset PMD patients with regard to hypochondriacal ideation, gastrointestinal symptoms and delusions of somatic, guilt and paranoid content.ConclusionsThe findings of the present study suggest considerable differences between young, elderly early-onset and elderly late-onset PMD patients with respect to their clinical features.

Does the Dexamethasone Suppression Test Reliably Discriminate Between Psychotic and Nonpsychotic Major Depression?

Previous research has shown that psychotic major depression (PMD) is often associated with higher rates of nonsuppression on the dexamethasone suppression test (DST) compared with nonpsychotic major depression (NMD), suggesting the potential importance of cortisol hypersecretion in the psychotic subtype of the disorder. However, these patient groups also are known to differ from one another on a variety of other clinical variables, and there are numerous factors independent of diagnostic status known to affect the DST. Thus, we investigated possible confounds that could help account for the apparent DST abnormalities in PMD sometimes reported in past research. Hospitalized patients with PMD (n = 11) and NMD (n = 58) were compared on the DST and other clinical variables. As expected, PMD patients showed significantly higher rates of DST nonsuppression (55% vs. 24%; p = 0.04). However, PMD patients also had significantly higher levels of anxiety severity (p = 0.01). The higher rates of nonsuppression in the PMD group were attenuated when these patients were compared with a subsample of NMD patients matched on anxiety severity (55% vs. 55%). Implications for future research on biological markers of PMD are discussed.

Psychotic (Delusional) Major Depression: New Vistas

In 1992, a comprehensive review of all previous studies comparing patients suffering from psychotic major depression (PMD) to non-PMD patients was published. In this review we present data of all studies comparing PMD patients to non-PMD published in the English language after 1992. The research papers reviewed have shown the following general profile of PMD: the point prevalence of PMD is about 0.4% and 19% of patients with a major depressive episode had psychotic symptoms as well. PMD was found to be a more severe form of depression with more feelings of guilt and more pronounced psychomotor disturbance. Additionally, PMD patients compared to non-PMD were found to be more severely impaired in the cognitive domains of attention, psychomotor speed, executive function and memory, regardless of depressions severity. As regards to the prognosis of the disorder, PMD is associated with poorer short-term outcome; nevertheless, in the long-term period ( > 2-5 years) the prognostic significance of delusions in major depression tends to become weaker. However, the recurrence of psychotic episodes in PMD patients suggests that PMD runs “true to form”. Of note, young PMD patients with acute onset of the disorder are at greater risk to develop bipolar disorder. Furthermore, PMD was associated with greater HPA abnormalities, higher plasma cortizol levels during the afternoon, lower serum D H activity than age-matched non-PMD patients and healthy controls. In addition, more brain atrophy and paralimbic abnormalities may play a crucial role in the delusion formation. With respect to management of PMD, starting with a combination of AD plus AP or AD as monotherapy may be preferred. Nevertheless, methodological problems in studies on SSRIs as monotherapy and according to recent data -favoring the combination over AD monotherapy- the AP plus AD treatment regime takes precedence. Keywords: Psychotic depression, delusional depression, major depressive episode with psychotic features

Prevalence and clinical characteristics of psychotic versus nonpsychotic major depression in a general psychiatric outpatient clinic

Psychotic major depression (PMD) is a severe mental disorder characterized by high levels of illness severity, chronicity, impairment, and treatment resistance. However, most past research on PMD has been conducted in inpatient hospital samples, and relatively little is known about PMD patients presenting for treatment in the community specifically. In this study, we examined the prevalence and clinical characteristics of PMD in a large sample (n=2,500) of treatment-seeking outpatients who were administered structured clinical interviews by trained diagnosticians. Of the patients diagnosed with major depression, 5.3% had psychotic features. PMD patients were more likely to be members of a racial/ethnic minority and to have lower educational attainment compared to those with nonpsychotic major depression. In addition, PMD patients were found to have greater current depression severity, suicidal ideation, and social and work impairment. These patients also were more likely to have histories of suicide attempts and psychiatric hospitalizations, to report an earlier age of illness onset, and to meet criteria for chronic depression. In terms of psychiatric comorbidity, PMD patients had higher rates of certain anxiety disorders as well as more somatoform and cluster A personality disorders. Results indicated that PMD was present in a relatively small percentage of treatment-seeking outpatients but was associated with disproportionately high levels of severity and impairment. Similarities and differences between the current findings and those from past research are discussed, including clinical implications for the identification and treatment of PMD in routine practice settings.

Depressive symptom profiles and severity patterns in outpatients with psychotic vs nonpsychotic major depression

Background Previous research suggests that patients with psychotic major depression (PMD) may differ from those with nonpsychotic major depression (NMD) not only in psychotic features but also in their depressive symptom presentation. The present study contrasted the rates and severity of depressive symptoms in outpatients diagnosed with PMD vs NMD. Method The sample consisted of 1112 patients diagnosed with major depression, of which 60 (5.3%) exhibited psychotic features. Depressive symptoms were assessed by trained diagnosticians at intake using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and supplemented by severity items from the Schedule for Affective Disorders and Schizophrenia. Results Patients with PMD were more likely to endorse the presence of weight loss, insomnia, psychomotor agitation, indecisiveness, and suicidality compared with NMD patients. Furthermore, PMD patients showed higher levels of severity on several depressive symptoms, including depressed mood, appetite loss, insomnia, psychomotor disturbances (agitation and retardation), fatigue, worthlessness, guilt, cognitive disturbances (concentration and indecisiveness), hopelessness, and suicidal ideation. The presence of psychomotor disturbance, insomnia, indecisiveness, and suicidal ideation was predictive of diagnostic status even after controlling for the effects of demographic characteristics and other symptoms. Conclusions These findings are consistent with past research suggesting that PMD is characterized by a unique depressive symptom profile in addition to psychotic features and higher levels of overall depression severity. The identification of specific depressive symptoms in addition to delusions/hallucinations that can differentiate PMD vs NMD patients can aid in the early detection of the disorder. These investigations also provide insights into potential treatment targets for this high-risk population.

Dysfunctional cognitions in hospitalized patients with psychotic versus nonpsychotic major depression

Previous research suggests that psychotic major depression (PMD) is associated with greater illness severity and functional impairment as well as poorer treatment response to antidepressants and psychotherapies compared with nonpsychotic major depression. Although patients with PMD exhibit a number of neurobiological abnormalities, little research has been conducted to date on possible psychological factors that are related to illness in this depression subtype. In the current study, baseline data were pooled from 2 clinical trials in which depressed patients (n = 235) were recruited during a psychiatric hospitalization for an acute episode. Twelve percent (n = 28) of this treatment-seeking sample met criteria for PMD and showed elevated levels of depression severity and dysfunctional beliefs compared with individuals with nonpsychotic major depression. However, even after controlling for depression severity and other relevant baseline variables, only a measure of common dysfunctional beliefs differentiated those with vs those without psychotic features. Furthermore, higher levels of depressive cognitions were related to poorer psychosocial functioning and suicidality in PMD patients. Results suggest that elevated levels of common negative cognitions in depressed patients may be associated with the presence of more severe psychotic symptoms. Adapted cognitive-behavioral treatments may be useful for treating patients with PMD specifically.

The Neuropsychological Profile of Psychotic Major Depression and its Relation to Cortisol

Our study described the neuropsychological profile of psychotic major depression (PMD) compared to nonpsychotic major depression (NPMD) patients and psychiatrically healthy controls (HC). We predicted that higher cortisol levels would be associated with greater cognitive deficits. Twenty-nine PMDs, 24 NPMDs, and 26 HCs were recruited at Stanford University Medical Center. Psychiatric ratings, cortisol levels from 1800-0900 hours, and neuropsychological test data were obtained. PMDs had more severe cognitive impairments compared with NPMDs and HCs with the exception of simple verbal attention. PMDs had elevated mean cortisol levels from 1800 to 0100 hours which were significantly correlated with poorer verbal memory and psychomotor speed performance. Cortisol slopes from 1800 to 0100 hours were also significantly correlated with verbal memory and working memory. While PMDs' ability to attend passively to information appears intact, they have more difficulty processing, manipulating, and encoding new information. Elevated cortisol levels, as seen in PMD patients, are associated with poorer cognitive performance especially related to verbal memory for lists of words and working memory.

Clinical and Biological Effects of Mifepristone Treatment for Psychotic Depression

Psychotic major depression (PMD) is found to be a relatively common psychiatric condition that affects up to nearly 20% of patients with major depression. Previous studies by our group have shown rapid reversal of psychotic symptoms in some PMD patients treated with mifepristone, in addition to restoring a more normal afternoon cortisol release. The rationale for treating patients with PMD with a glucocorticosteroid receptor antagonist is further discussed. In total, 30 patients with PMD were treated with either 600 mg/day mifepristone or placebo for 8 days in a randomized double-blind manner. The Hamilton Depression Rating Scale (HDRS) and the Brief Psychiatric Rating Scale (BPRS) were administered at baseline and again after 8 days of treatment. Cortisol and ACTH were measured hourly from 1800 to 0900 at baseline and after 8 days of treatment. Significantly, more patients in the mifepristone group (seven of 15) showed a 50% or greater decline on the BPRS positive symptom subscale, an index of psychotic symptoms, as compared to the placebo group (two of 15). Patients who received mifepristone had lower HDRS and BPRS scores at study completion compared to those who received placebo, but these differences were not statistically significant. In addition, mifepristone significantly elevated cortisol and ACTH levels and steepened ascending slopes from 1800 to 0100 and from 0100 to 0900 as compared to placebo. Clinical and biological effects of mifepristone were comparable among males and females. Age was found to significantly and positively correlate with changes in cortisol and ACTH. These results suggest that short-term use of mifepristone may be effective in the treatment of PMD and may re-regulate the HPA axis. Additional blinded studies are warranted.

Psychophysiological correlates of patients with delusional misidentification syndromes and psychotic major depression

Background: Psychotic major depression (PMD) and delusional misidentification syndromes (DMS) exhibit cognitive deficits. Since the P300 component of event-related potentials (ERPs) provides valuable information concerning cognition, we studied this component of ERPs in DMS and PMD patients. Methods: Nine patients with DMS, 15 patients with PMD, and 11 healthy controls, matched for age, sex and educational level, were tested using the auditory P300 component of ERPs. Results: Both patient groups showed significant reductions in P300 amplitude at the right frontal region, while DMS group showed significant attenuation of the P300 amplitude at the right parietal area. P300 latency was significantly prolonged in the central midline brain region in the DMS group. Limitations: The smallness of the sample size and the hypothetical post-hoc assignation of psychological function to regional activation. Conclusion: PMD and DMS patients may share similar psychophysiological alterations connected to the right frontal region, mediating automatic processes, while DMS are associated with dysfunction of effortful mechanisms and allocation of attentional resources involving the interhemispheric and right parietal circuitry.