Patients with postpsychotic depression may experience a longer period of untreated psychosis and feel greater shame, less control, and a greater sense of loss related to their illness, a study showed.
Depression during acute psychosis is associated most with prodromal depression, malevolence in voices, safety behaviors, and feelings of entrapment, the researchers reported.
To better understand depression with psychosis, Dr. Rachel Upthegrove of the University of Birmingham (England) and her associates assessed 92 patients, average age 22, presenting at the Birmingham Early Intervention Service with first-episode psychosis (FEP) and no history of treated psychosis. Of the participants 75% were male, and 70% met diagnostic criteria for schizophrenia, with a mean Positive and Negative Syndrome Scale (PANSS) positive score of 18.84. All but 10 were assessed at a 12-month follow-up.
Among the information gathered at baseline was lifetime diagnosis; the severity of current psychotic symptoms based on the PANSS; the duration of untreated psychosis; depression symptoms in the 6 months before FEP; acute depression symptoms based on the Calgary Depression Scale for Schizophrenia (CDSS); and feedback from the Personal Beliefs About Illness Questionnaire (PBIQ-R).
Additional information gathered involved beliefs about auditory hallucinations (malevolence, benevolence, and omnipotence); the perceived power of voices; characteristics of the experienced threat; and safety behaviors.
In the 6 months leading up to FEP, 56% of the participants had had a depressive episode, and during acute psychosis, 59% had a moderate or severe depression, 63% of whom had prodromal depression. At the 12-month follow-up, participants again were assessed with instruments including the CDSS, PANSS, and PBIQ-R. All but four (excluded) patients were in postpsychosis, and 37% had postpsychotic depression (Psychiatry Res. 2014 April 14 [doi:10.1016/j.psychres.2014.03.023]).
Overall, 22% of participants were depressed before, during, and after psychosis; 17% were depressed only during prodromal and acute phases; 20% had acute phase depression but not prodromal depression; 20% never experienced depression; and 5% had only postpsychotic depression.
During acute psychosis, PANSS scores among depressed and nondepressed patients were similar, but those with depression who heard voices perceived greater malevolence and less benevolence in the voices, and had greater engagement with the voices than did those who weren’t depressed but heard voices. Depressed patients also used more safety behaviors and "reported more powerful persecutors ... and were more distressed by the threat from persecutors than those who were not depressed," he said. Although overall insight scores were similar among depressed and nondepressed participants, depressed patients had greater awareness of their illness and greater negative illness appraisals.
Patients with postpsychotic depression had a longer duration of untreated psychosis, higher current low-level PANSS positive scores, and higher control, shame, and loss subscale scores on the PBIQ-R, compared with nondepressed patients post psychosis.
Dr. Upthegrove cited several limitations of the study. For example, data on the participants’ use of antidepressants were not recorded and might have affected the prevalence of depression. Also, the researchers who administered the semistructured interviews "were not blinded to baseline results, and thus there is ... a potential bias here." However, most key measures were self-reported, and this would minimize that potential effect, they wrote.
No outside funding source was noted, and the authors reported no disclosures.