Psychotic depression in hospitalized patients: Longitudinal outcomes of psychotic vs. nonpsychotic depression among inpatients

Highlights

• Psychotic depressive inpatients presented more severe psychopathology, worse functionality, and more disability.

• These clinical differences were present both at admission and at discharge.

• There were no differences in depressive symptom severity between psychotic and nonpsychotic patients.

• Psychotic depressive episode is a more severe form of the disease irrespective of intensity of affective symptomatology.

Abstract

Even though psychotic depression is related to worse outcomes than nonpsychotic depression, there is increasing evidence that this greater severity is not solely explained by the depressive symptoms. We evaluated the socio-demographic and clinical characteristics, as well as the differences in clinical outcomes of psychiatric hospitalization between psychotic and non-psychotic depression. Two-hundred-eighty-eight depressive inpatients were assessed within 72 h after hospitalization and 24 h before discharge. We compared scores of Hamilton Depression Rating Scale 17-items (HDRS-17), Clinical Global Impression (CGI), Brief Psychiatric Rating Scale (BPRS), and Global Assessment of Functioning (GAF) between psychotic and nonpsychotic patients. Instruments were compared both cross-sectionally – on admission and discharge – and longitudinally. Longitudinal outcomes were corrected for potential confounders (sex, age, age at disease onset, years of study, previous history of mania/hypomania, electroconvulsive therapy in current hospitalization, history of attempted suicide, number of suicide attempts, and previous hospitalizations). One-hundred-thirty-one depressive inpatients (45.4%) presented psychotic features. Both groups showed similar HDRS-17 scores at admission and discharge. However, psychotic patients had worse scores on BPRS, CGI, and GAF at both timepoints. Both groups had similar improvement on HDRS-17 (P = 0.75), CGI (P = 0.5), and GAF (P = 0.84), but psychotic patients had greater improvement on BPRS (P < 0.001). Psychotic inpatients showed worse clinical and functional parameters. Nonetheless, the groups did not differ in depressive symptom severity. These findings reinforce the hypothesis that depressive episode with psychotic features is a more severe form of the disease irrespective of intensity of affective symptomatology.

Introduction

Depressive episodes with psychotic features are possibly distinct, with discrete clinical characteristics, treatment, and prognosis in relation to the nonpsychotic form of the disorder (Johnson et al., 1991; Østergaard et al., 2014a; Jääskeläinen et al., 2017; Vermeulen et al., 2019). There is increasing evidence that the psychotic features in these patients cannot be explained exclusively by depressive symptom severity (Forty et al., 2009; Østergaard et al., 2012; Caldieraro et al., 2013). Also, psychotic depression is associated with alterations in brain functional connectivity and cognitive deficits in the elderly, regardless of severity of depressive symptoms (Oudega et al., 2019; Vermeulen et al., 2019). A considerable proportion of depressed individuals (10–18.5%) have psychotic symptoms during their lifetime (Johnson et al., 1991; Ohayon and Schatzberg, 2002; Zhou et al., 2020), and this rate might reach as much as 28% among hospitalized patients (Coryell et al., 1984; Baldwin and Jolley, 1986; Gournellis et al., 2001; Jääskeläinen et al., 2017).

Psychotic depression presents with a more severe clinical course of illness when compared to nonpsychotic depression (Jääskeläinen et al., 2017; Nietola et al., 2018). There are conflicting data regarding educational status. Whereas a systematic review found no statistically significant difference (Jääskeläinen et al., 2017), a recent larger study reported lower educational levels in psychotic compared to nonpsychotic depressive patients (Zhou et al., 2020). Psychotic depressive patients usually have more medical comorbidities (Gaudiano et al., 2016; Jääskeläinen et al., 2017), lower age at onset, and more hospitalizations (Nietola et al., 2018). Likewise, psychotic depression is associated with higher rates of suicide, attempted suicide, and suicidal ideation than nonpsychotic depression (Zalpuri and Rothschild, 2016; Gournellis et al., 2017, 2018; Zhou et al., 2020).

In particular, there is scant prospective evidence on the characteristics of psychotic depression and an increasing need to understand how psychosis interacts with mood episodes in mood disorders (Buoli et al., 2013; Seemüller et al., 2014; Toh et al., 2015; Nietola et al., 2018). In one naturalistic outcome study with depressed inpatients, approximately 10% of subjects had psychotic depression and presented a shorter time to relapse, suggesting the psychotic features represent a risk factor for relapse (Seemüller et al., 2014). Psychotic depression has also been linked to worse long-term prognosis compared to nonpsychotic depression (Copeland, 1983; Seemüller et al., 2014).

An optimal classification for depressive disorders has not yet been established (Mahli et al., 2005). Owoeye et al. (2013) suggested that major depressive psychotic disorder is more closely aligned with other psychotic diagnoses than previously thought. Few recent studies on psychotic illness have focused attention on the nosological, clinical, and biological characteristics of depressive disorder with psychotic features, or psychotic depression (Mahli et al., 2005; Buoli et al., 2013; Gaudiano et al., 2016; Zhou et al., 2020). This diagnostic category reflects the co-occurrence of symptom categories, depicting the intersection of dimensions of psychotic and affective psychopathology (Owoeye et al., 2013; Waddington and Buckley, 2013). Some authors suggest that a depressive episode is a diagnostic label that covers heterogeneous clinical presentations (Glassman and Roose, 1981; Helms and Smith, 1983; Waddington and Buckley, 2013).

The present study investigated differences and variations in clinical features between psychotic and nonpsychotic depressed inpatients throughout hospitalization. We addressed some socio-demographic and clinical characteristics on which there is conflicting evidence in the literature to better understand whether these are linked to a higher prevalence of psychosis. Our hypothesis is that psychotic depressive inpatients present more severe psychopathology and poorer functionality irrespective of intensity of affective symptomatology. Depressive symptoms intensity, general psychiatric symptoms, global severity, and functionality during the hospitalization period were assessed.