Challenges in the Treatment of Major Depressive Disorder With Psychotic Features

Anthony J. Rothschild

Disclosures

Schizophr Bull. 2013;39(4):787-796. 

In This Article

Summary

In summary, psychotic depression is associated with significant morbidity and mortality but is underdiagnosed and undertreated. In recent years, there have been several studies that have increased our knowledge regarding the optimal treatment of patients with psychotic depression. The combination of an antidepressant and antipsychotic is significantly more effective than either antidepressant monotherapy or antipsychotic monotherapy for the acute treatment of psychotic depression. Most treatment guidelines recommend either the combination of an antidepressant with an antipsychotic or ECT for the treatment of an acute episode of unipolar psychotic depression. 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. Unfortunately, the number of studies and number of tested antidepressant/antipsychotic combinations is quite limited. Clearly, more studies are needed to investigate other combinations that are commonly used in clinical practice along with studies of maintenance treatment. Little is known regarding the optimal treatment of a patient with bipolar disorder who has an episode of psychotic depression or the clinical characteristics of responders to medication treatments vs ECT treatments. Thus, there remain many questions for future research. Those that seem of greatest importance include the following: (1) what is the optimal maintenance treatment after a person responds to either the antidepressant/antipsychotic combination or ECT; (2) what are the clinical characteristics of responders to medication treatments vs ECT treatments; (3) decision trees to delineate the second and third lines of treatment when the first treatment is ineffective; (4) the efficacy of bilateral vs unilateral ECT; (5) differences in response and side effects to medication treatments and ECT in younger vs older patients; (6) the role of maintenance ECT; (7) what is the optimal treatment of a patient with bipolar disorder who has an episode of psychotic depression; and (8) do other combinations of antidepressant and antipsychotic medications that are commonly used in clinical practice have efficacy? The answers to these questions would be of significant practical utility to clinicians treating patients with psychotic depression.

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