Advances in the Treatment of Psychotic Depression
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Purpose of review
Our aim was to update the current understanding of effective treatment strategies for major depression with psychotic features (MDPSY).
Most treatment guidelines recommend either the combination of an antidepressant with an antipsychotic or electroconvulsive therapy (ECT) for the treatment of an acute episode of MDPSY. The optimal maintenance treatment after a person responds to either the antidepressant/antipsychotic combination or ECT is unclear particularly as it pertains to length of time the patient needs to take the antipsychotic medication. Further investigation into possible uses of ketamine, lithium carbonate, mifepristone, minocycline, and rTMS may produce possible new treatments in the future.
Unfortunately, there is no FDA-approved treatment for MDPSY. The combination of an antidepressant and antipsychotic is significantly more effective than either antidepressant monotherapy or antipsychotic monotherapy for the acute treatment of MDPSY.
KeywordsPsychosis Depression Antidepressants Antipsychotics Lithium Electroconvulsive therapy
Compliance with ethical standards
Conflict of interest
Dr. Rothschild has received grant or research support from Allergan, Janssen, the National Institute of Mental Health, Takeda, Eli-Lilly (medications for a NIH-funded clinical trial), Pfizer (medications for a NIH-funded clinical trial), and the Irving S. and Betty Brudnick Endowed Chair in Psychiatry; is a consultant to GlaxoSmithKline and Sanofi-Aventis; and has received royalties for the Rothschild Scale for Antidepressant Tachyphylaxis (RSAT)®; Clinical Manual for the Diagnosis and Treatment of Psychotic Depression, American Psychiatric Press, 2009; The Evidence-Based Guide to Antipsychotic Medications, American Psychiatric Press, 2010; The Evidence-Based Guide to Antidepressant Medications, American Psychiatric Press, 2012, and Up-to-Date®.
Drs. Malhotra and Thompson report no potential conflict of interest relevant to this article.
Human and animal rights and informed consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
- 4.Blazer D. Epidemiology of late-life depression. In: Schneider R, Lebowitz, Friedhoff, editors. Diagnosis and treatment of depression in late life. Washington DC: American Psychiatric Press; 1994. p. 9–20.Google Scholar
- 13.American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: Text Revision ed; 2010.Google Scholar
- 20.Rothschild AJ. Clinical manual for the diagnosis and treatment of psychotic depression. Washington, DC: American Psychiatric Press; 2009.Google Scholar
- 22.•• Nelson J, Bickford D, Delucchi K, Fiedorowicz JG, Coryell WH. Risk of psychosis in recurrent episodes of psychotic and nonpsychotic major depressive disorder: a systematic review and meta-analysis. Am J Psychiatry. 2018;175(9):897–904 Excellent review providing supporting evidence that psychotic depression is a distinct illness.PubMedCrossRefGoogle Scholar
- 24.Association AP. Practice guideline for the treatment of patients with major depressive disorder. 2010. http://www.psychiatryonline.com/pracGuide/PracticePDFs/PG_Depression3rdEd.pdf. 2018. Accessed 22 Jan 2019
- 25.Milev R, Giacobbe P, Kennedy SH, Blumberger DM, Daskalakis ZJ, Downar J, et al. CANMAT depression work group. Canadian network for mood and anxiety treatments (CANMAT) 2016 clinical guidelines for the Management of Adults with major depressive disorder: section 4. Neurostimulation treatments. Can J Psychiatr. 2016;61(9):561–75.CrossRefGoogle Scholar
- 26.Kennedy S, Lam RW, McIntyre RS, Tourjman SV, Bhat V, Blier P, et al. CANMAT depression work group. Canadian network for mood and anxiety treatments (CANMAT) 2016 clinical guidelines for the Management of Adults with major depressive disorder: section 3. Pharmacological treatments. Can J Psychiatr. 2016;61(9):540–60.CrossRefGoogle Scholar
- 27.Bauer M, Severus E, Köhler S, Whybrow PC, Angst J, Möller HJ. Wfsbp task force on treatment guidelines for unipolar depressive disorders. World Federation of Societies of biological psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders. Part 2: maintenance treatment of major depressive disorder-update 2015. World J Biol Psychiatry. 2015;16(2):76–95.PubMedCrossRefGoogle Scholar
- 28.Bauer M, Pfennig A, Severus E, Whybrow PC, Angst J, Möller HJ. World Federation of Societies of biological psychiatry task force on unipolar depressive disorders. World Federation of Societies of biological psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders. World J Biol Psychiatry. 2013;14(5):334–85.PubMedCrossRefGoogle Scholar
- 29.National Institute For Health and Clinical Excellence (NICE). The treatment and management of depression in adults (updated edition)—National Clinical Practice Guideline. 2010. http://www.nice.org.uk/nicemedia/live/12329/45896/45896.pdf. 2018. Accessed 22 Jan 2019
- 31.Dutch National Steering Committee Multidisciplinary Guideline Development Mental Health (DNSC). Multidisciplinary Guideline Depression. 2005.Google Scholar
- 33.Wijkstra J, Lijmer J, Burger H, Cipriani A, Geddes J, Nolen WA. Pharmacological treatment for psychotic depression. Cochrane Database Syst Rev. 2015;2015(7):1–65.Google Scholar
- 35.Meyers B, Flint AJ, Rothschild AJ, Mulsant BH, Whyte EM, Peasley-Miklus C, et al. STOP-PD group. A double-blind randomized controlled trial of olanzapine plus sertraline vs olanzapine plus placebo for psychotic depression: the study of pharmacotherapy of psychotic depression (STOP-PD). Arch Gen Psychiatry. 2009;66:838–47.PubMedPubMedCentralCrossRefGoogle Scholar
- 39.Anton RF Jr, Burch EA Jr. Amoxapine versus amitriptyline combined with perphenazine in the treatment of psychotic depression. Am J Psychiatry. 1990;147: 1203–1208.Google Scholar
- 50.Martell C, Addis M, Despression in Context JN. Strategies for guided action. New York: Guilford; 2001.Google Scholar
- 51.Hayes S, Strosahl K, Wilson K. Acceptance and Commitment therapy: the process and practice of mindful change. 2nd ed. New York: Guilford; 2012.Google Scholar
- 60.•• Gournellis R, Tournikioti K, Touloumi G, Thomadakis C, Michalopoulou PG, Michopoulos I, et al. Psychotic (delusional) depression and completed suicide: a systematic review and meta-analysis. Ann General Psychiatry. 2018;17:39–53 Excellent review of risk of suicide and psychotic depression.CrossRefGoogle Scholar