Depression in patients with schizophrenia during an acute psychotic episode

doi:10.1053/comp.2001.24577

Comprehensive Psychiatry

Volume 42, Issue 4, July 2001, Pages 314-318

https://doi.org/10.1053/comp.2001.24577 Get rights and content

Abstract

There is disagreement about whether depressive symptoms in schizophrenia are part of the basic disease process, or whether they represent adverse effects of treatment with antipsychotic medications. In a sample of initially antipsychotic drug-free acutely hospitalized patients with schizophrenia (N = 104), we measured change in depressive symptoms after 4 weeks of treatment. We also examined the relationship of changes in depressive symptoms to changes in positive and negative schizophrenic symptoms. Depressive symptoms improved after 4 weeks of antipsychotic medication treatment, and their improvement corresponded with improvement in both positive and negative schizophrenic symptoms. These results suggest that depressive symptoms in schizophrenia are related to the disease process itself, at least during acute exacerbations of schizophrenia. Depressive symptoms may be responsive to antipsychotic medications directly or as a secondary response to improvement in positive and negative symptoms.

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Treating depressive symptoms in patients with schizophrenia is challenging. While transcranical Dicrect Current Stimulation (tDCS) improved other core symptoms of schizophrenia, conflicting results have been obtained on depressive symptoms. Thus, we aimed to expand current evidence on tDCS efficacy to improve depressive symptoms in patients with schizophrenia.
A double-blind RCT was performed with patients randomized to 2 mA active-tDCS or sham-tDCS (15 daily sessions) with a bilateral bipolar-nonbalanced prefrontal placement (anode: left Dorsolateral prefrontal cortex; cathode: right orbitofrontal region). Clinical outcomes included variations of Calgary Depression Scale for Schizophrenia total score (CDSS) and of Depression-hopelessness and Guilty idea of reference-pathological guilt factors. Analysis of covariance was performed evaluating between-group changes over time. The presence/absence of probable clinically significant depression was determined when CDSS > 6.
As 50 outpatients were included (both groups, n = 25), significant improvements following active-tDCS were observed for CDSS total score (p = 0.001), Depression-hopelessness (p = 0.001) and Guilty idea of reference-pathological guilt (p = 0.03). Considering patients with CDSS>6 (n = 23), compared to sham, active-tDCS significantly improved CDSS total score (p < 0.001), Depression-hopelessness (p = 0.001) but Guilty idea of reference-pathological guilt only marginally improved (p = 0.051). Considering response rates of clinically significant depression, important reductions of CDSS score were observed (78 % of the sample scored ≤6; active-tDCS, n = 23; sham-tDCS, n = 16; p = 0.017). Early wakening item did not significantly change in any group.
The study lacks a follow-up period and evaluation of tDCS effects on psychosocial functioning.
Bilateral bipolar-nonbalanced prefrontal tDCS is a successful protocol for the treatment of depressive symptoms in patients with schizophrenia.
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Mood disorders and schizophrenia affect millions worldwide. Currently, diagnosis is primarily determined by reported symptomatology. As symptoms may overlap, misdiagnosis is common, potentially leading to ineffective or destabilizing treatment. Diagnostic biomarkers could significantly improve clinical care by reducing dependence on symptomatic presentation.
We used deep learning analysis (DLA) of resting electroencephalograph (EEG) to differentiate healthy control (HC) subjects (N = 239), from those with major depressive disorder (MDD) (N = 105), MDD-atypical (MDD-A) (N = 27), MDD-psychotic (MDD-P) (N = 35), bipolar disorder-depressed episode (BD-DE) (N = 71), BD-manic episode (BD-ME) (N = 49), and schizophrenia (SCZ) (N = 122) and also differentiate subjects with mental disorders on a pair-wise basis. DSM-III-R diagnoses were determined and supplemented by computerized Quick Diagnostic Interview Schedule. After EEG preprocessing, robust exact low-resolution electromagnetic tomography (ReLORETA) computed EEG sources for 82 brain regions. 20 % of all subjects were then set aside for independent testing. Feature selection methods were then used for the remaining subjects to identify brain source regions that are discriminating between diagnostic categories.
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The use of superseded DSM-III-R diagnostic system and relatively small sample size in some disorder categories that may increase the risk of overestimation.
DLA of EEG could be trained to autonomously classify psychiatric disorders with over 90 % accuracy compared to an expert clinical team using standardized operational methods.
The Persian version of the Calgary Depression Scale for Schizophrenia (CDSS-P)
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Determining depression symptoms in schizophrenic patients is a challenging process because of a degree of similarity between depression symptoms and negative symptoms and the extrapyramidal side effects of neuroleptic drugs, but it is crucial to evaluate and measure depression among patients with schizophrenia for a better clinical outcome. The Calgary Depression Scale for Schizophrenia (CDSS) is a valid and reliable instrument used for the evaluation of depression in schizophrenia. This study aimed to determine the psychometric properties of the Persian version of CDSS in a sample of people with schizophrenia. Clinical interviews were conducted with 95 schizophrenic patients (40 inpatients and 55 outpatients), who were assessed with the Positive and Negative Syndrome Scale (PANSS), Hamilton Depression Rating Scale (HDRS-17 and HDRS-24 items), and the Calgary Depression Rating Scale (CDSS). Then an exploratory factor analysis was conducted to determine correlations between scales, Cronbach’s alpha, and cutoff scores. The factor analysis led to the extraction of a unifactorial solution. The CDSS had significant relationships with PANSS Negative and PANSS General. However, it had no significant relationship with PANSS Positive and the PANSS Total. The CDSS also had significant relationships with HDRS-17 and HDRS-24. In addition, Cronbach’s alpha of total score, test-retest reliability, and cutoff score were estimated at 0.86, 0.82, and 8 (sensitivity = 0.79 and specificity = 0.84), respectively. The findings support the CDSS unifactorial approach. Results also showed that the CDSS Persian version had acceptable psychometric properties; thus, it could be employed to evaluate depression among schizophrenic patients.
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Citation Excerpt :
Gender as a predictor of course of depression has not been examined. Reduction of positive psychotic symptoms has been found to correlate with improvement of depression, however with less valid depression rating instruments (Norman and Malla, 1994; Tapp et al., 2001). Impact of schizophrenia spectrum vs. non-spectrum psychoses and antipsychotic-naivety on anti-depressive effectiveness has not been investigated before (Zhu et al., 2017).
Depression is common in schizophrenia and associated with negative outcomes. Previous studies have identified heterogeneity in treatment response in schizophrenia. We aimed to investigate different trajectories of depression in patients suffering from psychosis and predictors of change in depressive symptoms during antipsychotic treatment. Two hundred and twenty-six patients >18 years acutely admitted due to psychosis were consecutively included and the follow-up was 27 weeks. The Calgary Depression Scale for Schizophrenia (CDSS) sum score was the primary outcome. Latent growth curve (LGCM) and Growth Mixture Models (GMM) were conducted. Predictors were the Positive sum score of the Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Schizophrenia spectrum/non-spectrum psychoses, gender and being antipsychotic naive at inclusion. We found support for three depression-trajectories, including a high- (14.7%), a low depression-level (69.6%) class and a third depressed class quickly decreasing to a low level (15.7%). Change in CDSS was associated with change in PANSS positive score in all time intervals (4 weeks: b = 0.18, p < 0.001, 3 months: 0.21, p < 0.023, 6 months: 0.43, p < 0.001) and with a diagnosis within schizophrenia spectrum but not with antipsychotic naivety or gender. The schizophrenia-spectrum patients had less depressive symptoms at inclusion (−2.63, p < 0.001). In conclusion, an early responding and a treatment refractory group were identified. The treatment-refractory patients are candidates for enhanced anti-depressive treatment, for which current evidence is limited. The post-psychotic depression group was characterized by depressive symptoms in the acute phase as well. We could not identify differentiating characteristics of the depression trajectories.
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