Anthony J. Rothschild, MD
Irving S. and Betty Brudnick Endowed Chair & Professor of Psychiatry
Director, Center for Psychopharmacologic Research & Treatment
University of Massachusetts Medical School Department of Psychiatry
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Reducing the High Risk of Suicide Through Improved Recognition and Treatment of Psychotic Depression
A: Well, I got interested in psychotic depression when I was a resident in training in Psychiatry in the early 1980’s. At that time there was a great interest in Hypothalamic-Pituitary-Adrenal-Axis abnormalities in depression. Concurrently, I was doing research that showed people with psychotic depression had a very high prevalence of abnormalities on the Hypothalamic-Pituitary-Adrenal-Axis or HPA testing. This sparked my interest not just in psychotic depression but research in general. Over time, I began to take care of many people with psychotic depression as a part of enrolling them in research studies and I learned a lot about their care and treatment which lead to other interests in finding better ways to treat people with psychotic depression.
A: The most difficult part is recognizing the psychotic symptoms. The depression symptoms are fairly straight forward because people will complain about those symptoms. The psychotic symptoms are the hard part to diagnose because the people are often very guarded and are sometimes a little paranoid. They often will have an awareness that their thoughts are not quite right, so as a result, they keep the psychotic symptoms to themselves.
A: Yes, it is under recognized. In fact, we published a study in 2008 called Misdiagnosis of Psychotic Depression at Four Academic Medical Centers which was published in the Journal of Clinical Psychiatry. We showed that about 27% of the time the diagnosis of psychotic depression is missed in emergency room and inpatient settings and the reason it is missed is because the psychotic symptoms are not recognized.
A: I guess the short answer is no. Psychotic depression can occur at any age. In fact, there are people who may have their first episode of psychotic depression in their 60’s, 70’s and 80’s. In fact at one point it used to be called Involutional Melancholia and was thought only to be a disorder that occurred in the geriatric population but it can actually occur at any age. One thing to mention is that when it occurs in adolescence or people under the age of 25, studies have shown that there is a high prevalence of a later developing manic episode and so those people often end up having bipolar disorder even the young onset psychotically depressed. So, the short answer is it can occur at any age.
A: Yes, studies have shown that the risk of completed suicide and suicide attempts is higher in psychotic depression compared to non-psychotic depression. In some studies of psychotic depression they have shown a 5 fold higher rate of suicide than in non-psychotic depression. In other studies of suicide attempts or people who have made a suicide attempt, if they have psychotic symptomatology after the suicide attempt, research shows they have a 3-fold higher risk of making a suicide attempt than non-psychotic people. So, both completed suicide and suicide attempts are higher in people with psychotic depression compared to non-psychotic depression.
A: The American Psychiatric Association Practice guidelines are very clear and recommend either electroconvulsive therapy (ECT) or the combination of an anti-depressant and an anti-psychotic. These are the two most effective therapies for psychotic depression.