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Depression with Psychotic Symptoms More Difficult to Treat

Major depressive disorder (MDD) can be difficult to treat, requiring the patient to test out a variety of treatment options over a period of time before finding a prescription that works. MDD that results in poor treatment outcomes after following traditional antidepressant therapy is commonly thought of as being a sign of undetected bipolar disorder or bipolar spectrum features. Yet a new study is indicating that depression of this sort may rather be untreatable due to psychotic symptoms.

Individuals with MDD who have also experienced a psychotic episode—such as hearing voices, believing to have special powers, or paranoia about being watched, controlled, or plotted against—are more likely to have poorer treatment outcomes than others who have depression with symptoms of bipolar disorder or without psychotic-like symptoms.

A new study led by Dr. Roy H. Perlis of Massachusetts General Hospital and Harvard Medical School, published on December 6 in the journal Archives of General Psychiatry, has found that depression with psychotic-like symptoms is strongly associated with poorer treatment outcomes. Additionally, depression that results in poor treatment outcomes is not necessarily influenced by bipolar disorder. Dr. Perlis and his research team conducted a randomized, controlled trial involving 4,041 male and female U.S. adult psychiatric outpatients who were diagnosed with DSM-IV non-psychotic MDD based on data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D). The researchers followed the patients’ progress as they received open treatment for their depression using citalopram (Celexa) and up to three next-step treatments. To begin with, 30% (1,198 patients) were found to exhibit at least one feature of psychosis, and 38.1% (1,524 patients) were found to have at least one manic or hypomanic symptom—characteristic of bipolar disorder.

Of the study’s population, patients with psychotic symptoms were significantly less likely to respond well to antidepressant treatment. Among patients who exhibited symptoms of bipolar disorder, those patients who experienced irritability were more closely associated with poor treatment outcome. However, patients who exhibited the prominent symptoms of bipolar disorder, such as having a history of manic symptoms, a family history of bipolar disorder, or bipolar spectrum features, were not associated with poor treatment outcome from antidepressants.

The presence of bipolar spectrum features among depressed patients, therefore, did not determine their likelihood of resulting in poor response to antidepressants. Rather, psychotic-like symptoms were the most closely associated with poorer outcomes. The researchers’ findings suggest that unrecognized bipolar disorder is not as widespread among untreatable depressed patients as has typically been asserted by previous research. However, the researchers maintain that screening for bipolar disorder and other risk factors among psychiatric patients remains a pertinent treatment tool.

Source: HealthDay, Steven Preidt, Depression With Psychotic-Like Symptoms Seems Tougher to Treat, December 6, 2010

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