Psychotic Depression Can Be Effectively Treated but is Often Tragically Missed

Anthony J. Rothschild, M.D., University of Massachusetts
Anthony J. Rothschild, M.D.

From The Quarterly, Summer 2011

Psychotic depression, which is major depressive disorder combined with psychotic delusions or hallucinations, often goes undiagnosed. The kinds of delusions that tend to typify this condition often involve fears, such as the loss of a home or supposed threats by the I.R.S., which may not be apparent as delusion to an attending psychiatrist. The patient may also not divulge his fears out of shame or distrust. Studies have estimated the prevalence of psychotic depression among people diagnosed with depression at anywhere from 14 percent to close to 50 percent. The higher percentage is found largely among geriatric patients.

In addition to psychosis, other symptoms more common in this form of depression include increased motor disturbances, either severe agitation or severe slowing up; cognitive impairment; feelings of guilt and hopelessness; hypochondria; anxiety and sleep disorders. The mortality rate from general medical causes is twice that of those with depression without psychosis, the reasons for which are still unclear, and the suicide rate is five times higher.

Dr. Rothschild is one of only a handful of psychiatrists in the United States who have made psychotic depression a focus of their research. Among his studies, he conducted a collaborative effort with three other medical centers which found that the illness was completely missed in the emergency room or the inpatient setting 27 percent of the time. One simple expedient he suggests is having a family member present to corroborate whether or not the patient really is being pursued by the IRS (or their other fears).

Two treatments are recommended for treating psychotic depression: an antipsychotic medication combined with an antidepressant or electroconvulsive therapy (ECT). Most of the time, however, the only treatment administered is an antidepressant, which studies have shown is ineffective. In another multisite study, Dr. Rothschild and team found that only five percent of a sample group of patients with psychotic depression were properly medicated. The irony is that despite the severity of the disorder, these patients can actually achieve complete relief when appropriately treated. However, since both of these treatment regimes involve potentially negative side effects, one of the questions Dr. Rothschild is currently interested in investigating is how long patients should be kept on treatment after their symptoms have abated.