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Depressive Symptoms Common, Neglected in Early Schizophrenia
Sharon Worcestor, Clinical Psychiatry News Digital Network
January 23, 2012
Depressive symptoms are common and tend to be neglected in patients with first episode schizophrenia spectrum disorders, according to a medical file audit involving records for more than 400 patients.
Of 405 patients with an available baseline Clinical Global Impressions-Severity of Illness Scale-Bipolar Illness (CGI-BP) depression score, 106 (26.2%) had moderate to severe depression at service entry, Sue M. Cotton, Ph.D., of the University of Melbourne, and her colleagues report in the January issue of Schizophrenia Research.
Among the characteristics of patients with moderate to severe depression at service entry, compared with those without depressive symptoms, were a significantly greater likelihood of a past history of major depressive disorder (MDD; odds ratio, 2.58) and suicide attempts (OR, 1.55), a family history of psychiatric disorder (OR, 1.40), and significantly reduced likelihood of a past history of substance use disorder (OR, 0.67), the investigators found (Schizophr. Research 2012;134:20-6).
The patients with depressive symptoms also were more likely to have current MDD (OR, 5.52), and to have partial/full insight into their psychotic disorder (OR, 0.68), and they were less likely to have a current substance use disorder (OR, 0.65).
During treatment they were less likely to be admitted to the hospital (OR, 0.79), with a lower number of admission (OR, 0.84), and were less likely to be using substances (OR, 0.40).At discharge they were more likely to be depressed and to have partial/full insight to their illness (OR, 2.04 and 0.70, respectively), the investigators said.
Data on antidepressant medication use were available for 254 patients, and of those with moderate to severe depressive symptoms, 45 (55.6%) were prescribed antidepressants; these patients had significantly higher CGI-BP depression scores than did those with depressive symptoms who were not prescribed antidepressants.
The audit also provided descriptive characteristics of the 15 patients with persistent depressive symptoms and the 91 without persistent depressive symptoms (of the 105 patients with moderate to severe depressive symptoms at service entry). For example, those with persistent symptoms were significantly more likely to have a past diagnosis of personality disorder, as well as a diagnosis of a personality disorder at service entry (OR, 10.88 and 3.81, respectively).
Personality disorder diagnoses at service entry included borderline personality disorder, schizotypal, antisocial personality disorder, and personality disorder not otherwise specified.
Patients with persistent depression were also significantly more likely to have a past history of suicide attempts as compared with the two other groups (OR, 2.54).
Those patients with persistent depression had a shorter duration of treatment, all were noncompliant with treatment, and they were more likely to have ongoing substance use. At discharge, they had a significantly higher CGI symptom severity score, a lower global assessment of functioning mean score, and were less likely to be working, the investigators noted.
Of 81 patients with depression for whom antidepressant treatment information was available, 4 had persistent depressive symptoms and 77 did not. All four of those with persistent symptoms received treatment, and 41 of those without persistent symptoms received treatment.
The findings regarding the prevalence of depressive symptoms support the notion that the condition is common in early schizophrenia, and the fact that only about 29% of those with depressive symptoms had a comorbid clinical diagnosis of major depressive disorder at service entry might reflect underdiagnosis or underreporting of MDD. That finding also might be a sign that depressive symptoms are neglected in first episode of schizophrenia (FES) treatment, with more emphasis being placed on management of positive and negative symptoms, the investigators suggested.
"This may also be compounded by the lack of detail in clinical guidelines regarding the best treatments (including antidepressant use and psychotherapy) for depressive symptoms in FES," they said.
The findings underscore the need for assessing FES patients for depression at service entry, and for monitoring those with a history of depression, suicidality, and greater insight into their psychotic illness for depression over time, they added.
Although data on therapeutic interventions for those with depression in FES are scant, available data suggest that pharmacotherapy might be indicated. Requirements for such therapy might vary depending on the stage of the psychotic illness.
"For example, during the acute psychotic episode, antipsychotic medication may be the best treatment option, as observational studies have indicated that depression often subsides when the acute psychotic symptoms are treated," the investigators noted.
Cognitive therapies might also be useful and should focus on shifting negative appraisals of the self and the diagnosis of postpsychotic depression.
"Undoubtedly, controlled trials are needed to help determine the efficacy of pharmacological and psychological therapies for depressive symptoms in FES. Importantly, the findings of the current study are helpful for characterizing the appropriate target groups for such studies," they added, noting that understanding the nature and characteristics of depression in FES has important clinical implication for both early intervention and outcome in FES patients, particularly in regard to quality of life.
The findings of this study must be considered in the context of the medical file audit methodology used – an approach potentially limited by medical record quality and lack of inter-rater reliability, but the widely used methodology also offers several benefits, including the fact that a highly representative sample of patients can be obtained, the investigators said.
Future prospective research should focus on "mapping the trajectory of depressive symptoms against the course of positive and negative symptoms, insight, and substance use," they concluded, noting that such studies will improve understanding of the phenomenology and trajectory of depressive pathology in FES and inform the development of targeted interventions.
This study was supported by grants from Eli Lilly & Co. Australia and the Leenaards Foundation, Switzerland. Dr. Cotton is supported by the Ronald Phillip Griffith Fellowship, the University of Melbourne. Several other study authors reported that they serve on Eli Lilly’s speakers board.
Sharon Worcestor, Clinical Psychiatry News Digital Network
January 23, 2012
Depressive symptoms are common and tend to be neglected in patients with first episode schizophrenia spectrum disorders, according to a medical file audit involving records for more than 400 patients.
Of 405 patients with an available baseline Clinical Global Impressions-Severity of Illness Scale-Bipolar Illness (CGI-BP) depression score, 106 (26.2%) had moderate to severe depression at service entry, Sue M. Cotton, Ph.D., of the University of Melbourne, and her colleagues report in the January issue of Schizophrenia Research.
Among the characteristics of patients with moderate to severe depression at service entry, compared with those without depressive symptoms, were a significantly greater likelihood of a past history of major depressive disorder (MDD; odds ratio, 2.58) and suicide attempts (OR, 1.55), a family history of psychiatric disorder (OR, 1.40), and significantly reduced likelihood of a past history of substance use disorder (OR, 0.67), the investigators found (Schizophr. Research 2012;134:20-6).
The patients with depressive symptoms also were more likely to have current MDD (OR, 5.52), and to have partial/full insight into their psychotic disorder (OR, 0.68), and they were less likely to have a current substance use disorder (OR, 0.65).
During treatment they were less likely to be admitted to the hospital (OR, 0.79), with a lower number of admission (OR, 0.84), and were less likely to be using substances (OR, 0.40).At discharge they were more likely to be depressed and to have partial/full insight to their illness (OR, 2.04 and 0.70, respectively), the investigators said.
Data on antidepressant medication use were available for 254 patients, and of those with moderate to severe depressive symptoms, 45 (55.6%) were prescribed antidepressants; these patients had significantly higher CGI-BP depression scores than did those with depressive symptoms who were not prescribed antidepressants.
The audit also provided descriptive characteristics of the 15 patients with persistent depressive symptoms and the 91 without persistent depressive symptoms (of the 105 patients with moderate to severe depressive symptoms at service entry). For example, those with persistent symptoms were significantly more likely to have a past diagnosis of personality disorder, as well as a diagnosis of a personality disorder at service entry (OR, 10.88 and 3.81, respectively).
Personality disorder diagnoses at service entry included borderline personality disorder, schizotypal, antisocial personality disorder, and personality disorder not otherwise specified.
Patients with persistent depression were also significantly more likely to have a past history of suicide attempts as compared with the two other groups (OR, 2.54).
Those patients with persistent depression had a shorter duration of treatment, all were noncompliant with treatment, and they were more likely to have ongoing substance use. At discharge, they had a significantly higher CGI symptom severity score, a lower global assessment of functioning mean score, and were less likely to be working, the investigators noted.
Of 81 patients with depression for whom antidepressant treatment information was available, 4 had persistent depressive symptoms and 77 did not. All four of those with persistent symptoms received treatment, and 41 of those without persistent symptoms received treatment.
The findings regarding the prevalence of depressive symptoms support the notion that the condition is common in early schizophrenia, and the fact that only about 29% of those with depressive symptoms had a comorbid clinical diagnosis of major depressive disorder at service entry might reflect underdiagnosis or underreporting of MDD. That finding also might be a sign that depressive symptoms are neglected in first episode of schizophrenia (FES) treatment, with more emphasis being placed on management of positive and negative symptoms, the investigators suggested.
"This may also be compounded by the lack of detail in clinical guidelines regarding the best treatments (including antidepressant use and psychotherapy) for depressive symptoms in FES," they said.
The findings underscore the need for assessing FES patients for depression at service entry, and for monitoring those with a history of depression, suicidality, and greater insight into their psychotic illness for depression over time, they added.
Although data on therapeutic interventions for those with depression in FES are scant, available data suggest that pharmacotherapy might be indicated. Requirements for such therapy might vary depending on the stage of the psychotic illness.
"For example, during the acute psychotic episode, antipsychotic medication may be the best treatment option, as observational studies have indicated that depression often subsides when the acute psychotic symptoms are treated," the investigators noted.
Cognitive therapies might also be useful and should focus on shifting negative appraisals of the self and the diagnosis of postpsychotic depression.
"Undoubtedly, controlled trials are needed to help determine the efficacy of pharmacological and psychological therapies for depressive symptoms in FES. Importantly, the findings of the current study are helpful for characterizing the appropriate target groups for such studies," they added, noting that understanding the nature and characteristics of depression in FES has important clinical implication for both early intervention and outcome in FES patients, particularly in regard to quality of life.
The findings of this study must be considered in the context of the medical file audit methodology used – an approach potentially limited by medical record quality and lack of inter-rater reliability, but the widely used methodology also offers several benefits, including the fact that a highly representative sample of patients can be obtained, the investigators said.
Future prospective research should focus on "mapping the trajectory of depressive symptoms against the course of positive and negative symptoms, insight, and substance use," they concluded, noting that such studies will improve understanding of the phenomenology and trajectory of depressive pathology in FES and inform the development of targeted interventions.
This study was supported by grants from Eli Lilly & Co. Australia and the Leenaards Foundation, Switzerland. Dr. Cotton is supported by the Ronald Phillip Griffith Fellowship, the University of Melbourne. Several other study authors reported that they serve on Eli Lilly’s speakers board.
