Challenges in the Treatment of Major Depressive Disorder With Psychotic Features

Anthony J. Rothschild


Schizophr Bull. 2013;39(4):787-796. 

In This Article

Psychotherapeutic Treatment of an Acute Episode of Unipolar Psychotic Depression

The development of psychotherapeutic treatments for psychotic depression is in its early stages as patients with psychotic features have been excluded historically from psychotherapy trials of depression. Given the significant morbidity and mortality associated with psychotic depression, psychosocial treatments for patients with psychotic depression are urgently needed. Several studies suggest the potential utility of psychosocial interventions for the treatment of psychotic depression.[67–77]

Behavioral activation (BA)[78] and Acceptance and Commitment Therapy (ACT)[79] are 2 new approaches that show considerable promise for treating patients with depression or psychosis. BA involves the identification of an individual's behavioral avoidance patterns via functional analysis (ie, examining antecedents and consequences of behavior) and the development of a goal-oriented plan for changing these behavioral deficits using a stepwise process.[78] The goal of ACT is to promote increased psychological flexibility through acceptance of unavoidable distress, cultivation of a mindful outlook (ie, awareness of mental events as products of the mind rather than literal truths) to counteract excessive entanglement with cognitions, and clarification of personal values linked to behavioral goals.[79] Acceptance-Based Depression and Psychosis Therapy (ADAPT) is an integration of the BA and ACT approaches and was developed specifically for patients experiencing severe depression with co-occurring hallucinations or delusions.[67] A recent open-label study of 14 patients with psychotic depression treated with ADAPT showed promise when combined with pharmacotherapy.[67]