Psychotic depression differ from non psychotic depression in many ways.It has a distinct symptom profile,higher recurrence,poor quality of life and higher mortality rates. Even though up to 20% of major depression may belong to this subgroup, RCTs involving this group of patients are rare and hence there is less clarity on the best treatment approach.
Anne Katrine K. Leadholm and colleagues compare the guideline recommendations for psychotic depression.
The APA ( American Psych Assn), CANMAT(Canadian network), TMAP (Texas Medication Algorithm),and WFSBP ( World Fed Soc Bio Psych) guidelines have two first line treatment suggestions, namely either the combination of Antidepressant and Antipsychotics or ECT. DNBH (Danish Board) suggest either Antidepressant mono therapy or ECT as first line. SASOP ( South African Soc Psy) and RANZP( Royal Austr Newzea Coll) suggest only antidepressant and antipsychotic combination. NICE and Dutch National guidelines (DNSC) recommend only antidepressant mono therapy as first line.None of these suggest antipsychotic monotherapy.
Which antidepressant ?:DNBH, DNSC and the RANZCP suggest TCA. TMAP recommend SSRI or SNRI.Other guidelines ask clinician to select an agent suiting the patient.
Which antipsychotic? :DNSC suggests the use of typical APs.SASOP, TMAP and WFSBP endorse the first line use of atypical AP. Others offer no specific suggestion.
Augmentation: Augmentation with lithium is recommended by the APA, TMAP and RANZCP guidelines when the first line fails to achieve full remission. Other guidelines do not mention this.
Authors also report the results of their survey among Danish psychiatrists with regard to their preferences.
Psychotic depression (non-suicidal): 42% preferred antidepressant plus antipsychotic regimen, while 31% opted for antidepressant mono therapy .21% selected ECT.
Psychotic depression (high risk of suicide): 59% ECT, 27%-antidepressant plus antipsychotic.
Antidepressant of choice: majority selected TCA.(51%). 27% selected SNRI.
Antipsychotic of choice: 62% selected Quetiapine and 21% preferred Olanzapine.
Conclusions: Both guidelines and practice show high degree of heterogeneity. More studies required.
Comments: Even though there is less uniformity across guidelines, combination of antipsychotic with antidepressant or ECT is recommended by more guidelines.
Summary of the article:
Leadholm AK, Rothschild AJ, Nolen WA, Bech P, Munk-Jørgensen P, Ostergaard SD. J Affect Disord. 2013 Feb 20;145(2):214-20