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What is the Treatment Strategy for Major Depression with Psychotic Features

written by: Christina Garabedian • edited by: Emma Lloyd • updated: 9/5/2010

Discuss what actions may be displayed if a person has major depression with psychotic features. What is the treatment strategy for major depression with psychotic features? When could ECT be considered for treatment?

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    Major depression vs. major depression with psychotic features

    Up to 15% of those with major depression may develop psychotic features. The symptoms of major depression must be present along with evidence of psychosis for a diagnosis of major depression with psychotic features. Psychotic depression affects roughly one out of every four people who are admitted to the hospital for depression.

    According to the National Institute of Mental Health, a person who is psychotic is out of touch with reality. Hallucinations and delusions are indicators of psychotic features. A person may see or hear things that are not there and have unreasonable thoughts and fears that are not sensible.

    Symptoms may include

    • Agitation
    • Worry and tension
    • Constipation
    • Neurotic
    • Unable to sleep
    • Intellectual deterioration
    • Physical lethargic
    • Hallucinations
    • Delusions

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    What kind of treatments are available?

    The treatment for major depression is usually ongoing for long periods of time because the symptoms are most likely to reoccur but psychosis is not in most people.

    Treatment strategy for major depression with psychotic features

    • Anti-Depressants
    • Anti-psychotic medication for a brief period
    • Hospitalization to stabilize and monitor medication or if there is talk of suicide
    • Electroconvulsive therapy (if medication has not worked)

    Usually a combination of anti-depressants and anti-psychotics are the best treatment methods. Selective serotonin reuptake inhibitors(SSRI) seem to be effective along with the anti-psychotics as well. Lithium (mood stabilizer) is has been used for patients with psychotic depression if tricyclic anti-depressants can't be used.

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    Anti-depressants and anti-psychotics

    Anti-depressants are often prescribed to aid in relieving the major depression symptoms. Most often medication is taken long term to prevent relapse. Some anti-depressants can take up to 4 weeks to be effective. The side effects sometimes cause people to stop taking their medication but this is not recommend because stopping any medication without consulting a doctor may have negative consequences.

    Anti-depressant options

    • Monoamine oxidase inhibitors - MAO inhibitors work by blocking the chemicals that break down serotonin and norepinephrine.
    • Tricyclic antidepressants - work by correcting chemical imbalance.
    • Tetracyclic antidepressants - increases the levels of norepinephrine and serotonin in the brain.
    • Selective serotonin reuptake inhibitors - relieve symptoms of depression by blocking the reabsorption (reuptake) of serotonin by certain nerve cells in the brain.
    • Serotonin-norepinephrine reuptake inhibitors - increases the levels of both serotonin and norepinephrine by inhibiting their reabsorption (reuptake) into cells in the brain.

    Anti-psychotic medications

    No matter who prescribes the anti-psychotic there must be continuous follow ups with a psychiatrist while on this medication. Anti-psychotics are classified as typical and atypical. Atypical anti-psychotics are the newest and seem to have less permanet side effects such as Tardive dyskinesia

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    ECT for psychotic major depression

    ECT has side effects of temporary cognitive deficits such as confusion and memory problems, in addition to repeated exposures to general anesthesia. ECT is generally recommended if medications have been used and are not effective. Sometimes a person may not be able to wait for medication to take affect if there are suicidal tendencies, this is when electroconvulsive therapy may be an immediate option. The risk of suicide is much higher for those with major depression with psychotic features.

    In general ECT has been a way of immediate relief as a treatment strategy for major depression with psychotic features Electronconvulsive therapy does not have to be given long term as opposed to medication. There may be follow up sessions of ECT for maintenance in some cases.

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    Resources

    1. Diagnostic and Statistical manual of Mental Disorders - Fourth Addition (DSM-IV-TR) 2000

    2. Culpepper, L. (2007) A Roadmap to Key Pharmacologic Principles in Using Antipsychotics, Primary Care Companion To The Journal of Association of Medicine and Psychiatry 9(6) 444-454 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2139919/

    3. Alan F. Schatzberg, M.D. New Approaches to Managing Psychotic Depression http://www.psychiatrist.com/pcc/pccpdf/v05s01/v64s0104.pdf

    4. Psychotic Depression WedMD http://www.webmd.com/depression/guide/psychotic-depression

    5. Max Fink, M.D. ECT is an Effective, but Ignored, Treatment of Psychosis http://priory.com/psych/ectschiz.htm