Use of antipsychotics for psychotic depression especially on the long term is not evidence based. It obscures diagnoses and treatment outcome leading to omission of other effective treatments in order to obtain remission for psychotic depression.
Diagnosis and treatment of psychotic depression is surrounded by controversies and a matter of debate in science and psychiatry. The controversy around classification boils down to the question whether it is a severe form of depression or a separate form of depression. The controversy about treatment is whether antipsychotics are efficacious in the treatment of psychotic depression or antidepressants alone are sufficient. The disadvantage of antipsychotic treatment is side-effects and efficacy.
Two different articles on two blogs fortify these differences. On this blog a recent article discussed the differences between psychotic and non psychotic depression based on a recent article in Schizophrenia Bulletin.
Another opinion especially about treatment is discussed on Corpus Callosum. Mainly in the comments so don’t forget to read them. In a recent systematic review of the Cochrane Database no conclusive evidence was found that the combination of an antidepressant with an antipsychotic was better than the antidepressant alone.
A recent publication examined the patterns and predictors of medication use and two year course/outcome in first admission patients with psychotic depression (n=87). This was done in hospitals serving a county of 1.3 million people (Suffolk County Mental Health Project, US).
At discharge from their first admission 44.8% (39) used an antidepressant with an antipsychotic and only 8.1% (7) used antidepressant monotherapy. Overall 77% of patients used an antipsychotic at discharge and 58% an antidepressant. After 6 months 23% still used the combination, after 24 months 21.8% still used the combination. Antidepressant monotherapy did not change very much during follow up: 16% and 12%.
After 2 years 32% of patients still used antipsychotics and 39% antidepressants.
Only 29% achieved functional recovery by 24 months (GAF score).Only 40% had sustained remission for at least 19 months.
What this shows is that patients with psychotic depression have a risk of being prescribed antipsychotics for a long while without sufficient evidence of its efficacy. What is more alarming is that very effective treatments for psychotic depression such as ECT or lithium addition were not tried with partial remission.
Use of antipsychotics especially on the long term is not evidence based. It obscures diagnoses and treatment outcome leading to omission of other effective treatments in order to obtain remission for psychotic depression. There are several effective alternatives for nonresponse or partial response to antidepressants with or without antipsychotics, as can be read in this post with the title: 9 steps for treatment resistant depression
Compr Psychiatry. 2007 Nov-Dec;48(6):497-503. Epub 2007 Aug 20.
Medication use patterns and two-year outcome in first-admission patients with
major depressive disorder with psychotic features.
Craig TJ, Grossman S, Bromet EJ, Fochtmann LJ, Carlson GA.