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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 81-88

Critical appraisals on depression and psychotic symptoms

1 Department of Medical Elementology and Toxicology, Jamia Hamdard, Delhi, India
2 Department of Biotechnology, IIT Hyderabad, India
3 Centrefor Biotechnology and Bioinformatics, Dibrugarh University, Assam, India

Date of Submission14-Apr-2021
Date of Acceptance25-May-2021
Date of Web Publication13-Aug-2021

Correspondence Address:
Faizan Ahmad
Department of Medical Elementology and Toxicology, Jamia Hamdard, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnbs.jnbs_17_21

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Psychosis includes hallucination, illusion, and delusion. Psychotic symptoms are quite uncommon in disorders like posttraumatic stress disorder (PTSD) and Biploar affective disorder (BPAD) but Schizophrenia is a psychotic disorder. In this review, we focus on PTSD with psychosis, depression with psychosis and BPAD with psychosis. We mainly shed light on how psychosis related to PTSD, BPAD, and depression as well cover the pharmacological approach to deal with these disorders. We also extend our limit to other management like electroconvulsive therapy and lithium. The main aim of this review is to cover the role of psychosis in different psychiatric disorders and what are its present scenarios with future scope to combat it.

Keywords: Depression, drugs, posttraumatic stress disorder, psychotic symptoms

How to cite this article:
Ahmad F, Virmani A, Irfan M, Rankawat S, Pathak U. Critical appraisals on depression and psychotic symptoms. J Neurobehav Sci 2021;8:81-8

How to cite this URL:
Ahmad F, Virmani A, Irfan M, Rankawat S, Pathak U. Critical appraisals on depression and psychotic symptoms. J Neurobehav Sci [serial online] 2021 [cited 2023 Mar 24];8:81-8. Available from: http://www.jnbsjournal.com/text.asp?2021/8/2/81/323802

  Introduction Top

Some physicians claim that because current rapid depression treatment prevents it from being more severe, it is now rare to develop psychotic characteristics. Psychotic depression, in fact, is an ordinary disorder, under-recognized as well as treated defectively. In this analysis, the nuanced methods of complicating mood disorders by psychosis along with the process of changes in their path with reaction to cure are explored.[1],[2] Typical characteristics are described which are formally examined and to demonstrate more nuanced or compound presentations with other procedures to treatment, case examples are utilized. Over these years, the theory of the psychotic disorder has changed such that familiarity with earlier diagnosis criteria is difficult to adapt to more recent experience. Psychosis has been described to be as psychologically disabled in the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II), as the patient is not able to adjust with “the ordinary demands of daily life” and only from extreme disability, the psychotic depression was described, with or without the occurrence of delusions and hallucinations that are typical psychosis characteristics. In this elaboration, psychotic de-pressure is not a different condition and is at one end of a continuum of seriousness.[3],[4]

Psychotic depression's definition was updated in DSM-III [SJ for including hallucinations, delusions, and suicidal stupor after the description of a distinct therapeutic reaction, which was there for extensive depression with delusions but not for major depression without delusions. Although DSM-III removed extreme disability from the primary psychosis criterion, however in the International Classification of Diseases (ICD) this criterion still persisted, mostly for characteristics of endogenous. Even now, Psychotic depression is listed as a form of extreme extensive depression in ICD-10, the type continuing till 2022. The subsequent edition (ICD-11) includes, as diagnostic criteria, hallucinations and delusions along with severity. Psychotic depression and its definition have taken in a degree of se-truth in other diagnostic systems leading to the opposite of neurotic depression, endogenous depression, melancholic strain, or distortion of reality.[5],[6] A significant sub-type of major depressive disorder (MDD) is considered by various classifications to be psychotic illness. Moreover, in place of a distinct therapeutic process provided from a specific disease, an extreme form of MDD might actually need more of the same therapy as other presentations, is one of the implications of this idea. Psychotic disorder has become a significant subtype of MDD in DSM-IV, marked by delusions or hallucinations. It is also an MDD subtype in DSM-5 alternative to distinct condition, yet the describer of psychosis severity independent, meaning the pressure does not have to be extreme to warrant a psychotic depression diagnosis. In reality, DSM-5 enables dysthymia and major depression to have psychotic characteristics, accepting the concept that psychotic characteristics are not just a feature of depression severity. This shift represents an awareness that with or without psychosis, multiple depressive symptoms will arise, with varying consequences for prognosis and care. The opinion which says psychosis is inextricably not related to the intensity of depression is supported by literature survey. Rise of the total in psychotically depressed patients was completely due to the delusions or hallucinations subscale, in an examination of 357 hospitalized patients having severe depression, ICD-10, and with psychotic characteristics of their one-third peoples, on the 12-item Health of the Nation Outcome Scales severity rating scale. The extremity in depression was comparable on the condition of characterization of psychosis with the occurrence of hallucinations or delusions in nonpsychotic as well as psychotic classes, and this extremity was weakly associated with the seriousness of psychosis. In an analysis of 288 depressed patients, depression incidence was equal to 45% of psychotic patients and 55% of nonpsychotic depression, while in psychotic patients, functional disability was greater.[7],[8]

Patients without psychosis might be having similarities with serious depression, even though psychotic depression is extreme more often and many depression cases excluding hallucinations or delusions are related with higher severity of depression in comparison to instances of depression along with psychosis.[9] At a definite degree of mood disorder severity is required for the initial appearance of a tendency for psychosis as nonpsychotic episodes having a psychotic depression history are mostly shorter, without the severity like the psychotic episodes. Mostly following many episodes of nonpsychotic depression, when it does, insanity, which may not be as severe, appears to return including upcoming episodes.[10] While psychosis immediately does not follow each subsequent depressive episode, it is acting like an independent depression characteristic after arising, which modifies the condition of mood in functional means distinguishing from various depression types. An important duty is the diagnosis of psychosis in depressed patients, especially not responding to antidepressant therapy as anticipated when psychosis tries changing the treatment course and reaction of mood disorders rather than the severity of depression. It can be more apparent in examined patients in clinical trials than in clinical practise.

In psychotic depression, shifting diagnosis standards complicates the evaluation of various research.[11],[12] A study's clinical and theoretical effects rely on the characterization of psychosis with delusions or hallucinations, or intensity, melancholia, illness, or uni or bipolar major depressive episodes (MDEs) or if the control group comprised MDD with equivalent psychosis intensity, psychosis lacking depressive or depression against nonmelancholic depression. Different concepts and methods of diagnosis have led to differing estimates of psychotic depression prevalence. The prevalence in the general population was estimated to be 4/1,000 adults and 14–30/1,000 of those over the age of 60. Group studies reported that psychotic symptoms were present in adults of 10–19% with MDE. Studies in specialized settings indicate that 6%–25% of patients with MDD have psychotic characteristics. Psychotic characteristics were confirmed for approximately 24%–53% of geriatric patients and 25%–45% adult MDD patients. The true prevalence of psychotic diseases is probably underestimated as their symptoms in depressed patients are often ignored. [Figure 1] explains the development of psychotic symptoms inside the brain.[13],[14] [Figure 1] shows the formation of psychotic symptoms inside the brain and also explains the features of psychotic symptoms.
Figure 1: Development of psychotic symptoms inside brain

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  Missed Psychotic Depression Diagnosis Top

Data retrieved from the Pharmacotherapy of Psychotic Depression (STOP-PD) research, of the National Institute of Mental Health suggests that clinicians sometimes struggle to diagnose psychotic depression, primarily because of inadequate knowledge in the characteristics that are psychotic. Out of 130 diagnoses, a total of 27% were initially wrongly diagnosed with psychotic depression research diagnosis in a defined group of sufferers in the STOP-PD report. As patients with drug abuse history in the past 3 months and with comorbid situations or medicinal circumstances that are unbalanced were removed, a traditional estimation in the prevalence of the regular clinical people is likely to be the missed diagnosis rate found in this sample. Without psychopathic characteristics, depression else not defined (NOS), or mood disorder NOS, psychotic depression, most frequently misdiagnosed as a MDD. It was noticeable that none of the diagnosed patients were found to have a psychotic illness. This result shows that the psychosis was absent from the physicians rather than the mood disorder.[15]

  Bipolar Disorder and Psychotic Illness Top

Psychotic depression much presumably has a bipolar effect than nonpsychotic depression, and bipolar depression episodes are more often correlated with the indication of mental illness as compared to unipolar depression events. Indeed, in the course of a personality disorder, a good indicator of insanity is bipolarity.[16] 48.5% of people with psychotic illness in group studies have been diagnosed with bipolar I and 10.5% have been diagnosed with bipolar II mood disorders. In early-onset psychotic depression, bipolar disorder's subsequent detection is extremely frequent. The depression (psychotic) patients' relatives consist of common occurrences of bipolar condition apart from nonpsychotic depression patient's relatives, additionally, bipolar disorder patients' relatives that are depressed, have increased chances and presumably have psychotic characteristics as opposed to controlled ones in depression.[17] As in unipolar depression, at the onset of the mood disorder, psychosis associated with bipolar disorder, connected to the older generation, further affective symptomatology along with constancy, more number of entrances, increased comorbidity, extended hospitalizations, in psychiatry with worse prognosis. There is one side in the case of bipolar psychotic disorder where much awareness are not attained, in publications, the level at which combined components of raised energy along wind mental condition may contribute to people who is feeling but does not seem to be depressed, along with functioning at an elevated degree for patients with psychotic symptoms than the degree of symptomatology would expect.[18] The symptoms of such patients can be rejected as elaborated or suggestive of personality disorder, rendering real diagnosis misunderstood by the clinician. The recurrent incidence of nonauditory hallucinations is another characteristic of bipolar psychotic disorder that is easily ignored. It has been noted that visual hallucinations arise constantly, in bipolar apart from unipolar disorder, however olfactory as well as haptic hallucinations are also not uncommon. Patients who are not inherently affected by them may mitigate dramatic, mood-incongruent hallucinations, requiring patience to expose the psychosis.[19],[20]

  Posttraumatic Stress Disorder and Psychotic Illness Top

The history of childhood abuse in psychotic patients is 2–15 times greater than in nonpsychotic patients who are depressed. In a survey of 500 outpatient psychiatric patients, patients with psychotic disorder were four times more likely than those without psychotic depression to have comorbid posttraumatic stress disorder (PTSD) (57.9 vs. 15.7%; P = 0.0001). The finding that fight-related PTSD has a 30%–40% prevalence of psychotic symptoms put up the question of whether such individuals have PTSD with comorbid psychotic disorder, whether PTSD with psychosis is a different subtype of PTSD, or whether psychotic symptoms in PTSD have no clear medical or clinical meaning in contrast to depression.[21],[22] The trauma may or may not indicate psychotic symptoms in PTSD; cases in which PTSD with comorbid psychotic de-pressure instead of psychotic PTSD may not be cases. Few clinicians question whether “real” or “pseudo” psychosis is represented by psychotic symptoms that epitomise traumatic experiences. Flashbacks or dissociative re-experiencing of elements of trauma are hallucinations and delusions in this formulation, although empirical evidence supporting this formulation is variable. Forty-six percent to ninety-one percent supported hearing voices on one or both of two standardized instruments in 73 women treated for PTSD associated with childhood abuse and neglect. These symptoms are more likely to be present on instruments that asked many questions about them and were considered by the authors to be dissociative experiences that dissociate from “true” psychotic symptoms. Exceptionally, among patients who heard or did not hear voices, there was no difference in the use of antipsychotic drugs. Mixed evidence exists to assess whether antipsychotic drugs in PTSD with psychosis are consistently useful, or whether psychotherapy alone resolves “psychotic-like symptoms” in PTSD.[23],[24],[25],[26]

Depression is one of the conventional factors of PTSD, it can be very difficult to distinguish between psychotic depression in a patient with a history of trauma and PTSD with psychotic characteristics. Whether or not there are signs of comorbid PTSD, it is not clear that symptoms of psychotic disorders that specifically shows events in a patient if depressed which are traumatic for them (“trauma congruent” psychotic symptoms) consists various prognostic or clinical effects in contrast to the feature of psychotic behavior which are congruent with mood. It has not been studied to speculate that any of the relative treatment resistance reported with the psychotic disorder could be because of unrecommended PTSD. It is not yet clear if posttraumatic combination therapy is being used. Without a prior history of trauma, signs, psychosis as well as depression may be comparable to psychotic depression treatment.[23],[27]

  Schizophrenia Complicating Depression Top

The initial mood disorder, exacerbated by psychosis is referred to as psychotic depression. Far minimum data on primary nonaffective psychosis complicated by depressive episodes is accessible.[28] About 27%–48% schizophrenia depressive chapter acceptance is estimated, whereas 31% of patients aged in one study ranged from 27% to 48%. There were subsyndromal depressive symptoms for >55 years with schizophrenia spectrum disorder. Comorbid de-pressure is related to greater suicidality as well as additional negative, positive features in schizophrenia.[29],[30],[31],[32] Suicidality, pessimism, along with despondency, unique towards depression despite significant similarities among negative as well as depressive features, whereas alogia with blunted affect have extra consistently related with signs that are negative. In schizophrenia, the negative sign constitutes recognizable realms, the latter could be intensified by antidepressants, but several research disagrees, hence unclear if patients who replied were also depressed. It may be difficult in schizophrenia patients to determine the expressions that are depressive. Bradykinesia along with affective blunting induced by medications that are antipsychotic may also help to imitate depression, and antipsychotics with more potent D2 blockade may be related to dysphoria. A study has indicated that aripiprazole, clozapine, lurasidone, sulpiride, olanzapine, amisulpride along with quetiapine might be significantly much fruitful in relieving depressive characteristics of schizophrenia than other antipsychotics.[33],[34],[35] Both amisulpride and olanzapine decreased indications of depression in patients of schizophrenia in a clinical trial of 8 weeks, with 62%–66% of patients ranking on the Clinical Global Impression Scale as “much” or “very much” Conversely, the above analysis indicated “modest effectiveness” of the addition of an antidepressant for depression following schizophrenia. In an analysis of total patients of schizophrenia with the number 175 along with comorbid MDD, antidepressants decreased results of depression as well as generated 56% of de-pressure remission lacking improvement in the schizophrenia symptoms. No antidepressant seemed more effective than any other, while more extreme paranoia with comorbid drug use problems expected nonresponse. The antidepressant agomelatine was beneficial in patients with schizophrenia and MDD for the manifestation of negative and depression along with global psychopathology, however not for the indication of positive trait, while pharmacokinetic interactions with antipsychotic medications often occurred obtained from an open-label examination of 12 weeks.[36],[37],[38] List of different anti - depressant medicines are in described in form of [Table 1].
Table 1: Different anti-depressant medicines

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  Relevant Combinations of Medicines for the Acute Treatment of Psychotic Illness Top

Newer medicines (selective inhibitor of serotonin reuptake or inhibitor of serotonin-norepinephrine reuptake [SNRI] + antipsychotic second generation)

  1. Quetiapine plus venlafaxine[39]
  2. Olanzapine plus sertraline[40]
  3. Olanzapine plus fluoxetine.[41]

Older drugs (tricyclic antidepressant [TCA] + antipsychotic first-generation)

  1. Trimipramine plus haloperidol, amitriptyline[42]
  2. Perphenazine plus nortriptyline[43]
  3. Amoxapine, amitriptyline plus perphenazine[44]
  4. Perphenazine plus amitriptyline [Table 1].[45]

  Strategies for Augmentation Top

Lithium augmentation of antidepressants for nonpsychotic depression is the most commonly used technique for partial responders. However, in the treatment of psychotic disorder, lithium augmentation has not been extensively tested.[47] Lithium augmentation of the antidepressant/antipsychotic combination appeared to add additional efficacy in 4 limited, uncontrolled trials, especially in bipolar patients. There has been no analysis of the use of other augmentation methods or the use of lithium augmentation with other antidepressant and antipsychotic drug combinations.[48],[49] Of note, when the initial pharmacological regimen fails to enter complete remission, lithium augmentation is recommended by the APA, TMAP, and RANZCP guidelines. In the segment that addresses the treatment of the psychotic disorder, the other recommendations do not address lithium augmentation.[50],[51]

  Electroconvulsive Therapy Top

Most recommendations for the treatment of psychotic disorder advocate electroconvulsive therapy (ECT) as being at least just as successful as the proposed first-line pharmacological treatment. Only Good, RANZCP, and DNSC position ECT as a third and final alternative to be used if other therapies have failed or if, due to medical comorbidity or suicidality, an acute response is needed.[52] A lack of prospective, randomised trials limits the literature on the relative effectiveness of ECT compared with pharmacotherapy. Meta-analysis may provide the best opportunity to synthesize the effects of the reported treatment; however, it is difficult to draw large conclusions from these studies since ECT treatment was always compared at different doses and over different periods with many different combinations of medications. In a study of 17 prospective and retrospective trials involving Kroessler's 597 patients with psychotic disorder, 57 response rates were 82% for ECT and 77% for TCA and antipsychotic combinations, with slightly lower response rates of 51% and 34%, respectively, for antidepressant monotherapy or antipsychotic monotherapy.[53],[54] A second larger meta-analysis, which included data from 44 prospective and retrospective studies conducted between 1959 and 1988, 58 found that, with effect sizes of 2.30 and 1.16 respectively, ECT was substantially more effective than TCA alone.[55] An intermediate impact size of 1.56 was found to be a mixture of antidepressants and antipsychotics, which was not substantially different from the other two classes. Early initiation of ECT within 5 days of admission has been reported to shorten the duration of stay and minimize the cost of care, while ECT treatment in hospitals is associated with longer stays if treatment is not quickly started. Some findings indicate that for psychotic depression, ECT can be even more effective than for nonpsychotic depression. Far lower ECT remission rates have been reported in clinical practise in the community than in ECT clinical trials.[56],[57] The intent-to-treat remission rates of a large cohort of adults treated in community facilities with ECT were in the range of 30%–47%, for instance. Given the poor results of patients that do not remit with ECT, the low remission rates are of particular concern. The low remission rates in community practise may be explained by the fact that patients with comorbid mental and medical disorders correlated with worse ECT outcomes could constitute a greater proportion of the clinical population than patients studied in clinical conditions. Twenty-one percent said they would use ECT as first-line therapy in non-suicidal patients with psychotic depression in a survey of Danish psychiatrists. However, 59% would use ECT as the first-line treatment if the patient was at high risk of suicide.[58],[59],[60],[61]

  Directions for the Future Top

It seems like it is reasonably well delineated for definite psychotic unipolar strain's acute treatment. However, various principal affairs are not answered, even after considerable experience over several years. For a full response, first-generation antipsychotic drugs of heavy dose might be required by several patients. However, whether atypical antipsychotics, commonly used in psychotic depression, do the same, is not entirely known. It would be beneficial to remove antipsychotic medications as soon as possible or at least within a year, however, there is insufficient long-term evidence to establish if maintaining antipsychotic medication at the same or lower dosage is appropriate to avoid recurrence, as is the case for antidepressants in nonpsychotic depression. For the treatment of mania, antipsychotic drugs paired with mood-stabilizing drugs are often essential, although it is not yet clear if the combination of antipsychotic medication and a mood stabilizer is more effective than mood stabilizer monotherapy as an acute or maintenance treatment for psychotic bipolar disorder.

Increasingly, treatments using instrumentation including, repeated transcranial magnetic stimulation, vagus nerve stimulation, and deep brain stimulation were investigated as strategies of refractory depression, categorization eluding a range of psychotic depression cases. Furthermore, the treatment of auditory hallucinations repeated transcranial magnetic stimulation may have such uses. Controlled trials of these therapies for psychotic depression, particularly in psychotic depression cases which are not responding or unable to take other therapy or ECT, will definitely be justified. Another source of confusion is the clinical and diagnostic value of intermittent or mild expressions of disorders having psychotic features. Psychotic symptoms or indications constituting disturbing memories, like thinking of a past offender who has died is under surveillance or catching the sound of a mistreat victim, classify as legitimate unstable mind indications suggesting the requirement of supporting care along with drugs without the mood treatment alteration or an antipsychotic drug.

The total extent of responsibility to insanity demonstrated by past incidents of a family in parts of some mental condition combined with a temper defect is one of the most interesting neurobiological uncertainties to create a particular syndrome that is higher to the addition of its segments. No question arises here that more study elucidates the problems causing further effective remedy of the continuum of psychotic mood disorders.

  Conclusion Top

Psychotic features include hallucination, illusion, delusion, etc., which are not quite common in the case of depression. Sometimes MDD with psychosis might include delusion. In the case of PTSD and bipolar if psychosis arises with depression we use selective serotonin reuptake inhibitor, SNRI, lithium, and anti-psychotic medicine. Still, lots of clinical research needs to be done even diagnosing depression with psychosis is quite hard and very limited cases are reported in which ECT is used most of the time.

Patient informed consent

There is no need for patient informed consent.

Ethics committee approval

There is no need for ethics committee approval.

Financial support and sponsorship

No funding was received.

Conflicts of interest

There are no conflicts of interest to declare.

Author contribution subject and rate

  • Faizan Ahmad (50%-Conducting a literature review)
  • Anmol Virmani (10%-Conducting a literature review)
  • Mahammad Irfan (10%-Conducting a literature review)
  • Sourbh Rankawat (20%-Conducting a literature review)
  • Upasana Pathak (10%-Conducting a literature review).

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