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The Treatment of Psychotic Major Depression: Is There a Role for Adjunctive Psychotherapy?

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The Treatment of Psychotic Major Depression: Is There a Role for Adjunctive Psychotherapy? Special Article Psychother Psychosom 2007;76:271–277 DOI: 10.1159/000104703 The Treatment of Psychotic Major Depression: Is There a Role for Adjunctive Psychotherapy? a a b Brandon A. Gaudiano Ivan W. Miller James D. Herbert a Department of Psychiatry and Human Behavior, Brown Medical School and Butler Hospital, Providence, R.I. , and b Department of Psychology, Drexel University, Philadelphia, Pa. , USA Key Words There are several empirically supported biological and Major depression Psychosis Cognitive behavior therapy psychosocial treatment options currently available for in- Combined treatments Hospitalized patients, depression dividuals suffering from major depression. However, de- pression is a heterogeneous condition, and far less re- search has been conducted on the adaptation of treat- Abstract ments for specific diagnostic subtypes. Population studies Background: Psychotic depression is a relatively prevalent estimate that psychotic features (i.e. hallucinations and/ mood disorder associated with greater symptom severity, a or delusions) are present in 14–19% of patients with major poorer course of illness and higher levels of functional im- depression, giving it a lifetime population prevalence of pairment compared with nonpsychotic depression. Sepa- over 2% [1, 2] . The rates tend to be particularly high in rate lines of investigation suggest that various forms of cog- hospitalized depressed patients, with up to 25% meeting nitive-behavioral therapy are efficacious for treating severe criteria for psychotic depression (PD) [3] . In this paper, forms of nonpsychotic depression as well as primary psy- we review the clinical features of PD and present the pre- chotic disorders. However, there currently are no empirically liminary data to date on psychotherapy response in pa- supported psychotherapies specifically designed for treat- tients with PD. We then briefly discuss research and ing psychotic depression. Method: We review the efficacy of treatment implications based on current empirical knowl- current somatic treatments for the disorder and discuss the edge. limited data to date on potentially useful psychotherapeutic approaches. In particular, we describe the clinical improve- ment observed in a subgroup of hospitalized patients with Clinical Features and Course of PD psychotic depression treated with Acceptance and Commit- ment Therapy as part of a larger clinical trial. Results: Pilot Patients with PD can be differentiated from those with results demonstrated that Acceptance and Commitment nonpsychotic depression based on a number of neurobio- Therapy was associated with clinically significant reductions logical and neuropsychological abnormalities, including in acute symptom severity and impairment compared with distinct patterns of structural brain anomalies, hypotha- treatment as usual. Conclusion: The findings suggest that lamic-pituitary-adrenocortical axis activity, dopamine patients with psychotic depression can benefit from psycho- and serotonin neurotransmission, and cognitive deficits therapy. Clinical and research recommendations in this area [4–6] . Other clinical characteristics of PD include greater are presented. Copyright © 2007 S. Karger AG, Basel symptom severity, number of suicide attempts, psycho- © 2007 S. Karger AG, Basel Brandon A. Gaudiano 0033–3190/07/0765–0271$23.50/0 Psychosocial Research Program, Butler Hospital Fax +41 61 306 12 34 345 Blackstone Boulevard E-Mail [email protected] Accessible online at: Providence, RI 02906 (USA) www.karger.com www.karger.com/pps Tel. +1 401 455 6457, Fax +1 401 455 6235, E-Mail [email protected] motor disturbance, psychiatric comorbidity, axis II per- an with PD who refused to take medications using cogni- sonality features and functional impairment [3, 7–9] . tive therapy. However, we were unable to identify any Compared with nonpsychotic depression, PD is charac- full-scale clinical trials of psychotherapy specifically for terized by a longer duration of illness, more frequent hos- PD. Cognitive behavior therapy (CBT) – a general term pitalizations and relapses and a greater likelihood of re- we use here to refer to the family of closely-related cogni- current psychotic symptoms [10–12] . Further, the poorer tive and behavioral interventions – has been found to be outcomes in PD have been shown to be independent of efficacious either alone or in combination with medica- initial symptom severity, and patients continue to show tions to treat severe forms of depression [20, 21] . Further, poorer outcomes even after acute psychotic symptoms emerging evidence suggests that CBT produces medium dissipate [12–14] . Research suggests that clinicians often effect size gains beyond ‘treatment as usual’ for patients fail to thoroughly assess for psychotic symptoms and pa- with primary psychotic disorders [22, 23] . Although tients tend to underreport symptoms due to paranoia or some past research has included small numbers of pa- embarrassment [15] . The number of differences between tients with PD [24] , the vast majority of psychotherapy psychotic and nonpsychotic subtypes has led some to ar- studies have excluded these patients from trials. gue that PD should be recognized as a unique diagnostic There also is a paucity of research investigating wheth- entity [14] . er the poorer outcomes found in patients with psychotic versus nonpsychotic depression apply to treatments that include pharmacotherapy and psychotherapy. Gaudiano Current Somatic Treatments for PD et al. [13] recently reported response to combined treat- ments in patients with PD. The data were pooled from Patients with PD show a poorer response to antide- clinical trials in which patients with psychotic and non- pressant treatment with tricyclic or selective serotonin psychotic major depression were provided with effica- reuptake inhibitor medications alone compared with cious combined therapies (medication plus cognitive, be- nonpsychotic depressed individuals [5, 6] . Many authors havioral or family therapies). Although similar in sever- suggest that antidepressant plus antipsychotic treatment ity during acute hospitalization, patients with PD showed is superior to treatment with either medication alone, al- greater depression severity at postoutpatient treatment though the results have not always been consistent. In a and at 6-month follow-up. Following treatment, patients recent Cochrane Systematic Review, Wijkstra et al. [16] with PD were over 4 times as likely to exhibit severe levels concluded that currently there are insufficient data to of suicidal ideation and depression. The findings indi- support the superiority of combined antidepressant and cated that current state-of-the-art combined treatments antipsychotic treatment compared to antidepressant may have poorer efficacy in depressed patients with psy- monotherapy. Additional evidence suggests that electro- chotic symptoms, suggesting the need for adapted treat- convulsive therapy is an efficacious treatment for PD. ments better tailored to the needs of this population. Electroconvulsive therapy is at least as effective and in fact may be even more effective than combined antide- pressant plus antipsychotic therapy based on results from Pilot Findings Using an Acceptance-Based meta-analyses [5, 17] . However, electroconvulsive thera- Psychotherapy for PD py and neuroleptic medications have several disadvan- tages that can limit their effectiveness in clinical practice, Treatment Rationale and Description including side effects, safety concerns and symptom per- Feasibility data for the psychosocial treatment of PD sistence despite adequate treatment [5, 17, 18] . can be found in recent research using a brief form of Ac- ceptance and Commitment Therapy (ACT) [25] to treat acutely ill patients with psychotic spectrum disorders. Psychotherapy Response in PD ACT is similar to other emerging behavioral approaches that incorporate acceptance and mindfulness elements, Given the limitations of current somatic treatments such as dialectical behavior therapy [26] . Preliminary ev- for PD, a clear role exists for psychosocial interventions idence from over 10 preliminary randomized trials sug- that can be used adjunctively to treat this disorder. In one gests the efficacy of ACT for treating a wide variety of of the only reports of its kind, Bishop et al. [19] described problems, including anxiety and substance use disorders a case study detailing the successful treatment of a wom- [27] . The results from 2 small trials comparing ACT to 272 Psychother Psychosom 2007;76:271–277 Gaudiano /Miller /Herbert traditional CBT in depressed outpatients found that both Based on findings from an earlier trial [32] , Gaudiano produced similar improvements in depression by post- and Herbert [33] tested the efficacy of ACT in a sample treatment, but that ACT resulted in earlier changes in the of hospitalized patients with psychotic symptoms, which believability of negative cognitions [27] . Whereas tradi- included PD, schizophrenia, schizoaffective disorder and tional cognitive therapy [28] focuses on directly modify- bipolar disorder. The patients were taught to increase ing dysfunctional thought content through rational de- their acceptance of unavoidable distress, to simply notice liberation and guided discovery, ACT focuses on modify- their psychotic symptoms without treating them as either ing the person’s relationship to his/her thinking more true or false, and to identify and work toward personally broadly. The goals of ACT are
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