Depression In Schizophrenia

Rasit Tahsin duygudurum merkezi

Depression in Schizophrenia: Symptom, Syndrome or Co-morbidity? E. Timuçin Oral Assoc Prof of Psychiatry Bakırköy Prof Dr Mazhar Osman State Hospital for Research & Training in Neuropsychiatry Istanbul / Turkey

Facts about Schizophrenia 

Outcome      

~15% fully recovered ~ 85% have residual and/or active sx 90% or more are economically dependent 75% or more are unmarried ~ 10% die by suicide Mortality 2x more than healthy controls

Simple Courses 38%

Undulating Courses 58%

Atypical Courses 4% McKenna 2003

DSM-IV - Schizophrenia “The characteristics of Schizophrenia involve a range of cognitive and emotional dysfunctions that include perception, inferential thinking, language and communication, behavioral monitoring, affect, fluency, and productivity of thought and speech, hedonic capacity, volition and drive, and attention” APA. DSM-IV-TR; 2000.

Symptom Clusters in Schzophrenia Positive

Negative

Hallucinations Flattened affect

Cognitive

Affective

Learning

Depression

Delusions

Anhedonia

Memory

Anxiety

Bizarre behavior

Avolition

Attention

Aggression

Social withdrawal

Executive function

Dysphoria

Thought disorder Agitation

Alogia

Psychomotor activation Language skills

Pathological Dimensions of Schizophrenia

Negative Symptoms Affective flattening Alogia Avolition Anhedonia Social withdrawal

Positive Symptoms Delusions Hallucinations Disorganized speech Catatonia

Social/Occupational Dysfunction Work Interpersonal relationships Self-care

Cognitive Deficits Attention Memory Executive functions (e.g., abstraction)

Comorbid Substance Abuse

Mood Symptoms Depression Anxiety Hopelessness Demoralization Stigmatization Suicidality

Good Prognosis in Schizophrenia (?)     

Prominent affective symptoms Acute onset Family history of affective disorder Good premorbid function Presence of insight

Depressive symptoms in Schizophrenia 

M=F



Main indication for 40% of hospital admissions (Falloon et al, 1978)

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Associated with poor outcome, personal and social adjustment

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Treatment non-compliance & increased risk of suicide (Carpenter et al, 1988)

Comorbidity 

Obsessive-Compulsive disorder  



Depression 

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7.8% with schizophrenia had OCD 26% out of 50 patients met criteria for OCD

25% prevalence rate with Schizophrenia

Suicide  

10% of patients commit suicide Suicide attempts are 5 times higher than suicide rate

Lifetime Suicide Rates     

UP (alone) 10,4% Schizophrenia + UP 27,5% BP (alone) 28,5% Schizophrenia + BP 70.6% 37% at least one suicide attempt 7.9% in nonschizophrenic population (p<0.0001) (Judd, 1996)

  

40% reported suicidal ideation 23% reported suicide attempts 6.4% died

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Patients who died had lower negative symptom severity

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Suspiciousness and Delusions were more severe among suicides

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Paranoid subtype: elevated risk (12%) Deficit subtype: reduced risk (1.5%)

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Fenton, et al. Am J Psychiatry, 1997

Relationship Between Schizophrenia - Mood Disorders / Suicide 

CINP: Mood symptoms in schizophrenia are actually a manifestation of schizophrenia rather than a discrete mood disorder

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NIMH: Lifetime prevalence 1.5% (34 out of 20,291).

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NCS: 18.6% were schizophrenia without comorbid mood disorders (59% comorbid UP; 22% comorbid BP) (Judd, 1998)

Depression in Schizophrenia Often been associated with  Worse outcome (Falloon et al 1978)  Impaired functioning  Personal suffering (Siris, 2000)  Higher rates of relapse, rehospitalization and even suicide (10% of patients) (Mandel et al 1982; Roy et al 1983; Birchwood et al 1993; Caldwell-Gottesman 1990; Fenton et al 1997)

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Literature on depression in schizophrenia is imprecise whether the affect, symptom, or syndrome of depression is involved.

Affect, Symptom, Syndrome? 

Affect a mood state (happiness - sadness). Not pathological as long as situationally appropriate



Symptom a sad mood state causes a distress. An unwanted painful feeling a source of complaint.

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Syndrome a complex of features includes cognitive and vegetative features pessimism, guilt, impaired concentration, lack of confidence, loss of interest / pleasure, disturbances in sleep, appetite and energy level Siris SG, Am J Psychiatry 2000; 157:1379–1389

Objective To differentiate whether depression manifested as only a cluster of symptoms, a syndrome or a comorbid disease in schizophrenia (DSM-IV) 

97 out of 100 patients interviewed was participated

Inclusion Criteria Receiving same medication >1 year

Exclusion Criteria  

All other psychotic diagnoses, All other medical and psychiatric diagnosis

Scales    

Structured Clinical Interview for Diagnosis (SCID) Hamilton Depression Rating Scale (HDRS) Calgary Depression Scale for Schizophrenia (CDSS) Positive and Negative Syndrome scale (PANSS)

Definitions    

Dx of MD (SCID) = ‘co-morbidity group’ Scored > 8 (HDRS) + >12 (CDSS) = ‘syndrome group’ Scored < 8 (HDRS) / <12 (CDSS) = ‘symptom group’ Scored ≤ 2 (HDRS + CDSS) = ‘non-depression group’

Patient Characteristics

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47 Male (48,5%) and 50 Female (51,5%) patients. Mean age = 38.24 59.8% single, 21,6% married and 16,5% divorced. 53,6% elementary school, 46,4% high school

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82% unemployed, 15,5% still working

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86,6% in middle, 11,3% in lower, 2,1% in higher economic class

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10,3% living alone

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Illness Characteristics        

71,1% paranoid 16,5% undifferentiated 8,2% residual 4,1% disorganized Age of onset: 22,3 Age of treatment: 24,5 Median of prvious hospitalizations: 3 Mean duration of remission: 22,5 months.

Group Characteristics    

6 patients in co-morbidity group (6.2%) 10 patients in syndrome group (10.3%) 58 patients in symptome group (59.8%) 23 patients in non-depression group (23.7%)

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No gender, education, socio-economic and marital status differences in between groups

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Groups are identical in social support & SS coverage

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90% of patients in co-morbid and syndrome groups are unemployed

CDSS HAMD PANS-T Positive Negative

Symp

Synd

Comorbidity

Non-Dep

p

1,90 5,21

9,60 14,80

12,17 18,67

0,04 0,09

0,001 0,001

59,57 10,95 20,50

62,00 10,40 16,70

62,33 12,33 16,67

43,04 8,87 15,13

0,001 NS 0,01

Correlation of Depression Scales with PANNS-T r = 0,134; p = 0,190 CDSS *r = 0,367; p < 0,001 HAMD *PANNS General Sx subscale highly and significantly correlated with HAMD

CDSS HAMD PANS-T Positive Negative

Symp

Synd

Comorbidity

Non-Dep

p

1,90 5,21

9,60 14,80

12,17 18,67

0,04 0,09

0,001 0,001

59,57 10,95 20,50

62,00 10,40 16,70

62,33 12,33 16,67

43,04 8,87 p<0.04 15,13

0,001 NS 0,01

Correlation of Depression Scales with PANNS-T r = 0,134; p = 0,190 CDSS *r = 0,367; p < 0,001 HAMD *PANNS General Sx subscale highly and significantly correlated with HAMD

CDSS HAMD PANS-T Positive Negative

Symp

Synd

Comorbidity

Non-Dep

p

1,90 5,21

9,60 14,80

12,17 18,67

0,04 0,09

0,001 0,001

59,57 10,95 20,50

62,00 10,40 16,70

62,33 12,33 16,67

43,04 8,87 p<0.04 15,13

0,001 NS 0,01

p<0.001

Correlation of Depression Scales with PANNS-T r = 0,134; p = 0,190 CDSS *r = 0,367; p < 0,001 HAMD *PANNS General Sx subscale highly and significantly correlated with HAMD

   

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100% of comorbid group 90% of syndrome group 69% of symptom group 71% of non-depressed group were in paranoid sub-group Depression in 1° and 2° relatives   

4-6% in two groups 16.7% in co-morbid group None in non-depressed group

http://www.schizophrenia.com/schizpictures.html

Suicide rates    

2 in co-morbid group (33.3%) 2 in syndrome group (20%) 19 in symptom group (32.7%) 4 in non-depressed group (17.3%)

Treatment 

75 (78,9%) of all patients were receiving SGA  40% of symptom group & 30% of non-depressed patients were receiving clozapine  None of the patients were applied clozapine in comorbid group

Differential Diagnosis of Depression in Schizophrenia   3.    

Medical/Organic Factors Negative Symptoms of Schizophrenia Neuroleptic-Induced Dysphoria Neuroleptic-Induced Akathisia Reactions to Disappointment or Stress “Postpsychotic Depression” Prodrome of Psychotic Relapse Siris SG, Am J Psychiatry 2000; 157:1379–1389)

Antipsychotic Treatment & Depression

Antipsychotic Receptor Pharmacology Haloperidole

Klozapine

Olanzapine

Quetiapine

Risperidone

Sertindole

Ziprasidone

Zotepine

D1 D2 D4 5HT2A 5HT2C Musc a1 a2 H1

Results 

Frequency of depressive symptoms is common in schizophrenia; although it less likely manifests as a syndrome or as an additional diagnosis

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Defining depression and the severity of symptoms is important as they may play a devastating role in the course

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Positive symptoms must be taken into consideration seriously as they may be the “cause” of depression.

I am totally cured doctor. I am not paranoid anymore!

He is trying to convince me