Introduction
Depression with psychotic symptoms, or ‘psychotic depression’ (PD), is a severe condition characterised by the simultaneous presence of clinical depression and psychotic symptoms, mainly in the form of delusions, hallucinations and catatonia (Reference Rothschild1). PD is currently classified as a subtype of severe depression in both the Diagnostic and Statistical Manual of mental disorders, 4th revision (DSM-IV) (2) and the International Classification of Disease, 10th edition (ICD-10) (3). This dichotomous subtyping is based on the presence/absence of psychotic symptoms during depression, but research has shown that PD differs from non-psychotic depression in many other aspects (Reference Ostergaard, Petrides and Dinesen4–Reference Loo, Mahon, Katalinic, Lyndon and Hadzi-Pavlovic13).
It has previously been described that delusional themes in PD tend to be identical, or vary very little, over several episodes (Reference Charney and Nelson14,Reference Lykouras, Christodoulou and Malliaras15), but case reports illustrating this clinical phenomenon are lacking from the literature.
Case presentation
Ms. J is a 45-year-old woman who was referred to a general psychiatric hospital in Denmark due to severe depression with accompanying delusions. The first author of this manuscript met Ms. J as she participated in the study entitled ‘Clinical Validation of the Rating Scale for Psychotic Depression’ (ClinicalTrials.gov Identifier: NCT01518049). The case report is based on a review of her medical file. None of the authors have been involved in Ms. J's treatment in any way.
Ms. J's symptoms had developed over ∼2 weeks and had been noticed by her family members who were very worried about her well-being and safety. The contact to the psychiatric hospital was made by a nurse from the psychiatric outpatient clinic where Ms. J was receiving treatment because of previous episodes of severe depression. As Ms. J refused to be admitted voluntarily, compulsory admission was carried out in accordance with Danish law, which supports the admission and treatment of individuals who are psychotic and at risk of harming themselves.
At the initial interview at the psychiatric hospital, Ms. J displayed severely depressed mood, loss of interest, feelings of guilt and worthlessness, psychomotor retardation, anxiety and lack of insight. Apart from the depressive symptoms, she was tormented by the false belief that her 17-year-old son had suffered severe weight loss caused by her incompetence as a mother – not providing him with enough food and care. Contrary to her conviction, her son was a perfectly healthy teenager with a large and satisfied appetite. Both physical examination and biochemical screening of Ms. J were normal and there was no suspicion of intracranial pathology requiring brain imaging.
During the 1st week of the admission, Ms. J was under constant 24-h monitoring at a closed ward due to the risk of self-harm. After 2 days of stay she gave consent to bilateral electroconvulsive therapy (ECT), which had been used with very good response during previous episodes. After four bilateral ECT treatments she was no longer delusional and after 1 month of hospital stay, and a total of nine bilateral ECT treatments, she was discharged from the hospital for follow-up at the outpatient clinic. At this point, she was euthymic and demonstrated full insight in relation to her mental illness. The psychopharmacological regimen at the time of writing is 50 mg nortriptyline, 15 mg aripiprazole and 200 mg quetiapine (prolonged release). Before the episode described above, a variety of other psychopharmacological regimens had been employed in the attempt to prevent recurrence of Ms. J's depressive illness. These included lithium, olanzapine, risperidone, zuclopenthixol and chlorprothixen.
The course of the psychotic depressive episode described above is relatively common, but the particularity of Ms. J's case lies in its history. Her first depressive episode developed 7 months after the birth of her son, that is, 17 years before the present episode. At that time, she was admitted in a state of severe depression accompanied by the delusion that she was a bad mother, and the conviction that her son communicated that he did not want her breast milk, merely through the way he looked at her. She responded very well to ECT treatment and was discharged with the ICD-10 diagnosis of F32.3 – severe depressive episode with psychotic symptoms (3). Since this first episode, Ms. J has been admitted to a psychiatric hospital for treatment of depression 15 times during a total of 13 separate episodes. At all these occasions, she was delusional and the resulting ICD-10 diagnosis was F33.3 – recurrent depressive disorder, current episode severe with psychotic symptoms (3). The delusional theme at practically all of the depressive episodes concerned her son and various false beliefs with accompanying guilt feelings regarding his lack of well-being/safety. The following examples are representative of the delusions: ‘I have caused damage to my son's hearing and he will never recover’, ‘It was my fault that he fell down the stairs – my son would be better of without me’, ‘I will not let my son go to school because he is in danger and I'm to be blamed’. At some of the admissions, she also suffered from visual/auditory hallucinations (seeing/hearing her son) and catatonia (stupor). There are no reports of hypomanic, manic or mixed episodes and a recent screening with the hypomania checklist (HCL-32) (Reference Angst, Adolfsson and Benazzi16) was not indicative of bipolar disorder. During the admission in relation to episode number 9, Ms. J felt that the furniture at the department had ‘a special significance’ and had voices telling her that she was a bad mother. In the course of the same admission, she felt that her thoughts were being broadcast to her son and husband through radio waves. There are no other descriptions of bizarre delusions or Schneiderian first-rank symptoms in her medical file. In between episodes, Ms. J. has experienced some tendency towards self-reference/paranoia (mood-congruent), especially when feeling stressed in relation to work or family affairs. At some occasions, the self-referent ideas progressed to frank delusions and led to the admissions described above.
Discussion
In this case report, we describe a 45-year-old female who has experienced multiple episodes of unipolar PD, since its onset 17 years before the most recent admission. The theme of her delusions has been largely consistent over the many episodes and the depressive, psychotic and catatonic features have all responded extremely well to ECT.
It can be argued that the bizarre delusions and Schneiderian first-rank symptoms occurring during episode number 9 are incompatible with the ICD-10 definition of PD, according to which the delusions or hallucinations should be different from those ‘listed as typically schizophrenic in F20’ (3). Yet Ms. J was, rightfully in our opinion, diagnosed with PD again after this episode. In a recent paper of ours (Reference Ostergaard, Rothschild, Uggerby, Munk-Jorgensen, Bech and Mors17), we suggested the following regarding the psychotic symptoms in the ICD-11 diagnostic criteria for PD: ‘Psychotic symptoms (delusions or hallucinations) are present, but diagnostic criteria for schizophrenia or schizo-affective disorder are not fulfilled. However, bizarre delusions or Schneiderian first-rank symptoms persisting for <2 weeks during a depressive episode can still be classified as PD if the depression is the predominant state’ (Reference Ostergaard, Rothschild, Uggerby, Munk-Jorgensen, Bech and Mors17). This paper was written before the meeting with Ms. J, but her case emphasises quite clearly why the criteria for the psychotic symptoms in the ICD-11 definition of PD would benefit from the revision suggested above. The short bout of bizarre delusions and Schneiderian first-rank symptoms experienced by Ms J. does not change the overall impression of her course of illness as a case of recurrent PD. The criteria revision would also increase the consistency between DSM-5 and ICD-11, thereby facilitating research and improving transferability across the DSM/ICD border.
The treatment choices in the case discussed in this paper are not unusual as it reflects the lack of an established, clearly superior, pharmacological treatment regimen in PD (Reference Rothschild18). International treatment guidelines on PD have proven to be heterogeneous, with both antidepressant monotherapy and antidepressant–antipsychotic combination therapy being advocated as first-line treatment (Reference Leadholm, Rothschild, Nolen, Bech, Munk-Jorgensen and Ostergaard19). A recent meta-analysis on the optimal pharmacological treatment of PD concludes that antidepressant–antipsychotic combination therapy is significantly more effective than monotherapy with either an antidepressant or an antipsychotic drug (Reference Farahani and Correll20). However, the meta-analysis relies on the assumption that the effect of the combinations can be compared and summed (class effect), despite the use of entirely different antidepressants and antipsychotics in the individual studies (Reference Farahani and Correll20). When considering the heterogeneity in the pharmacological mechanisms of various antidepressants and antipsychotics, this assumption seems questionable. Furthermore, it remains unclear which antidepressant–antipsychotic combination is the most effective (Reference Leadholm, Rothschild, Nolen, Bech, Munk-Jorgensen and Ostergaard19).
Regarding ECT, almost all treatment guidelines on PD suggest ECT as a first-line treatment on par with pharmacological options, or as the superior choice in cases where severe suicidality or threatening somatic conditions are present [for a review see Leadholm et al. (Reference Leadholm, Rothschild, Nolen, Bech, Munk-Jorgensen and Ostergaard19)]. The present case supports the efficacy of ECT in the acute phase of PD, but also underlines that, despite successful ECT treatment, there is a high rate of relapse. This is consistent with the literature (Reference Sackeim, Haskett and Mulsant21–Reference Aronson, Shukla and Hoff23). An ongoing study may provide important new knowledge regarding an effective relapse preventing pharmacological regimen for PD (Reference Flint, Meyers and Rothschild24).
In conclusion, Ms. J's case illustrates that PD can be a stable phenotype over many episodes and that it is important to recognise psychotic symptoms in order to prescribe the best possible treatment of depression (Reference Leadholm, Rothschild, Nolen, Bech, Munk-Jorgensen and Ostergaard19,Reference Farahani and Correll20,Reference Fink25–Reference Rothschild, Winer and Flint27). In the present case, ECT has provided fast and safe response in the acute phase of illness, over many episodes in a time span of 17 years. Relapse prevention has been more challenging.
Acknowledgements
Ms. J has given written and oral consent to the publication of this case report. The authors are grateful for her participation.
Financial Support
S.D. Østergaard and A.K. Leadholm were funded by their respective institutions as listed under affiliations. A.J. Rothschild’s contribution was supported in part by the NIMH (U01 MH062624) and the Irving S. and Betty Brudnick Endowed Chair of Psychiatry, University of Massachusetts Medical School.
Conflicts of Interest
S.D. Østergaard has received consultant honoraria and travel support from Janssen-Cilag until April 2011. Furthermore, he has received travel support from Bristol Myers Squibb at one occasion in 2010. A.J. Rothschild has received grant support from the National Institute of Mental Health (NIMH), Cyberonics, Takeda, and St. Jude Medical and has served as a consultant to Allergan, GlaxoSmithKline, Eli Lilly, Noven Pharmaceuticals, Pfizer, Shire Pharmaceuticals, and Sunovian. A.K. Leadholm reports no conflicts of interest.
