Posted by temoigneur on June 16, 2005, at 2:42:21
In reply to Interesting article - HPA dysfunction in mood diso, posted by temoigneur on June 16, 2005, at 1:32:41
PSYCHOTIC MAJOR DEPRESSION (PMD)
http://psychoticdepressionalgorithm.stanford.edu/default.asp?main=main.asp
Click here for a detailed discussion of PMD, or click on one of the section titles below to see more details about that specific topic.
Clinical Features
Psychotic or delusional marked by the presence of hallucinations or delusions that occurs only coincident with the depressed mood symptoms.
Paranoid delusions may be the most common delusions.
Delusions appear to be more common than hallucinations.
Patients with PMD tend to demonstrate greater agitation, early and middle insomnia, depressed mood and guilt, and absence of diurnal variation, and greater cognitive impairment then patients with non-psychotic major depression disorder (MDD).
Diagnostic Criteria
Diagnostic Criteria for Major Depression with Psychotic Features
Adapted from Diagnostic and Statistical Manual of Mental Disorders
Fourth Edition DSM-IV
Published by the American Psychiatric AssociationDifferential Diagnosis
The most important differential diagnosis is with MDD.
PMD patients tend NOT to exhibit elements of a formal thought disorder that characterize schizophrenia.
Presence of bizarre delusions ("Aliens have planted a receiver in my head") appears to be less common in PMD than in schizophrenia.
Course
Episodes of PMD tend to be discrete and time limited.
Patients generally function well between episodes, both interpersonally and vocationally.
The psychosocial impairment does not typically approach that seen in schizophrenia.
PMD patients are more likely than MDD patients to be hospitalized in any given episode.
The average age of onset is in the 30s and 40s.
No difference between MDD and PMD patients in the risk of suicide.
Pathophysiology
PMD tends to be marked by the following:A marked abnormality of the hypothalamic pituitary adrenal (HPA) axis.
High levels of urinary free cortisol, basal serum cortisol levels, and high serum corticotropin releasing factor (CRF) levels.
High levels of unconjugated dopamine and the dopamine metabolite homovanillic acid (HVA) after dexemethasone administration.
Higher levels of tyrosine hydroxlase activity that can contribute to higher dopamine levels and activity.
Poorer sleep efficiency, reduced REM sleep, diminished slow wave sleep, and a higher percentage in stage one sleep.
Higher levels of serotonin metabolites (5-HIAA), and higher rates of platelet serotonin reuptake.
Treatment
PMD is less likely than MDD to respond to placebo and to monotherapy with either antidepressants or antipsychotics.
Only 25-40% of patients respond to tricyclic antidepressants.
Typical antipsychotics alone appear to be ineffective in the treatment of PMD, although they do help with the psychotic symptoms
Atypicals alone may also be ineffective in PMD.
Combination of an antidepressant and an antipsychotic appears to be necessary for the treatment of PMD.
Recommended Treatment Strategies
First line strategy might be the combination of an atypical agent and either an Selective Serotonin Reuptake Inhibitor (SSRI) or venlafaxine.
A second line strategy might be the combination of a tricyclic antidepressant (TCA) with an atypical antipsychotic or the use of amoxapine.
ECT may have a more reliable track record in improving symptoms than pharmacological treatments.
Experimental Treatment Strategies
Current studies looking at on glucocorticoids antagonists, such as C-1073 (mifepristone or RU 486), which works by blocking the GR II receptor in the brain.
Transcranial Magnetic Stimulation (TMS) is being investigated as an alternative to ECT in the treatment of depression.
poster:temoigneur
thread:513549
URL: http://www.dr-bob.org/babble/20050611/msgs/513560.html