Delusional Disorder Management

1. Evidence Based Management of Delusional
Disorder
Presented by:
Dr. S.M. Yasir Arafat
Resident Psychiatry
Bangabandhu Sheikh Mujib Medical University
March 01, 2016.

2. Article Particulars
Title: Current Treatments for Delusional Disorder
Journal: Current Treatment Options in Psychiatry
Publisher: Springer International Publishing
DOI 10.1007/s40501-015-0044-7
Volume: 2015
Issue: 2
Page: 151-167
DOP: 11 April 2015
Type: Review Article

3. Authors Particulars
1. Mohsen Jalali Roudsari, MD
2. Jinsoo Chun, Ph.D.
3. Theo C. Manschreck, MD, MPH
Address
1. Harvard Common- wealth Research Center,
USA
2. Department of Psychiatry, Beth Israel Deaconess
Medical Center, USA
3. Department of Psychiatry Harvard Medical
School, USA

4. Introduction
A cardinal characteristic of delusional
disorder, conviction that one is not
mentally ill, contributes complexity to the
treatment challenges and profoundly
affects the therapeutic relationship
A significant problem in treating DDs is
the limited available evidence based on
RCTs

5. Objectives
Review of recent contributions on
pharmacological treatment of DD
Updating the current directions in relevant
psychological therapies

6. Methods
PubMed to find the pharmacological
treatment in English between 2012 & 2014
Selection criteria: Adequate diagnostic
accuracy, treatment descriptions &
outcome information
24 articles including 15 CRs with 25 cases,
one case series of 50 cases and 6
observational studies with 384 cases

7. Result & Discussions: Demographics
Gender difference with female preponderance
Diagnosed more frequently in middle-aged or
elderly
The mean age of onset in recent reports was
older than 45 Y
Women became ill significantly later than men
DD appears with relatively high diagnostic
stability over time. (10 Y; 79 %) that is more in
females

8. R & D: Comorbidities
• Diagnosis of comorbidities is crucial, since
these conditions may influence response to
treatment
• The majority of studies on DD reported
depression as the most frequent comorbidity
• de Portugal et al., 2011 found 46% of DD had at
least one additional lifetime psychiatric
diagnosis
• Depressive disorders (32.6 %) was the most
common, followed by anxiety disorders (14 %)

9. R & D: Antipsychotics
• Optimistic outcomes with antipsychotics with a
high positive response rate—remission or partial
remission
• Regarding the frequency of use, FGA used to be
the drugs of choice for DD
• There is no controlled trial to compare between
FGAs and SGAs
• Two early reports showed no difference
• Introduction of atypicals & SE of pimozide, SGAs
have been used more frequently
• Risperidone used as the most frequent
medication (24 %) followed by olanzapine,
quetiapine, and FGA

10. R & D: Choice of Antipsychotics
• SE features as a criterion for drug selection
• Age of the patients, the presence of
comorbid conditions, and drug interactions
• Pimozide seems no longer to be the first
choice
• SGA metabolic SE
• The initial dosages in DD were lower than
the dosage recommended for the treatment
of schizophrenia

11. R & D: Antipsychotics
Antipsychotic Recovery Partial
improvement
No
improvement
SGA (17) 8 4 5
FGA (3) 3 0 0
SGA+FGA (1) 1 0 0
Antidepressant (2) 1 1 0
Psychotherapy (1) 1 0 0
Non (1) 1 0 0
Total (25) 15 5 5
Antipsychotics and outcomes—25 case reports

12. R & D: Antipsychotics
Antipsychotic Recovery Partial improvt No improvt
Risperidone (12) 8 3 1
Olanzapine (9) 5 3 1
Amisulpride (7) 3 3 1
Quetiapine (5) 3 2 0
Aripiprazole (5) 4 1 0
Paliperidone (5) 4 1 0
Iloperidone (2) 2 0 0
Fluoxetine (5) 5 0 0
Total (50) 34 13 3
Antipsychotics and outcomes—Bhatia et al.

13. R & D: Combinations
• SSRIs & SNRIs are the medications often used
in DD treatment despite some common side
effects
• Combining different psychotropic agents is a
frequent approach in DD treatment
• Antidepressant, valproate, or psychotherapy
can be combined
• A recent review study on the affective
symptoms in DD noted relatively high
antidepressant efficacy either as monotherapy
or in combination with anti- psychotics

14. R & D: LAIs
• At 1 year, higher treatment maintenance
rates and less antidepressant and BDZ
usage was found in LAIs group compared
to oral SGAs
• LAIs group showed a trend toward lower
scores in PANSS positive symptoms &
significantly lower scores in PANSS negative
symptoms

15. R & D: Psychotherapy
Cognitive Behavioral Therapy (CBT)

16. Limitations
Not a systematic review

17. Recommendations
RCTs with systematic outcome measures
are required to address treatment
efficacy

18. Conclusion
Both pharmacological and psychological therapies
have demonstrated impact
FGA & SGA agents have shown positive results;
pimozide and clozapine also have value despite
side effects and limited evidence
LA antipsychotic agents have shown impact as
well
Strategy is to select agents based on SE risks, ease
of administration, and acceptability to the patient

19. Other Related Articles
Recent Advances in the Treatment of
Delusional Disorder
Review Paper (94-04 ) by Manschreck & Khan
Can J Psychiatry, Vol 51, No 2, February 2006
Pimozide and FGA, as well as SGA, and
even clozapine can be used
A positive response to medication treatment
occurred in nearly 50% of the cases

20. Take Home Message
Paucity of evidence, based on RCT
FGA, high potent and SGA with high D2
activity
Antidepressants, mood stabilizers & CBT play
roles
Co-morbidities need to be addressed
Selection should be based on SE risks, ease of
administration & patient conditions

21. Presenter’s Comments
Review article
Recent article
Aligned with DSM-5

22. References
Available with request

23. Acknowledgements
Dr. Md. Hafizur Rahman Chowdhury
Faculty Members
Dr. Hosne Ara

24. Queries????
“The important thing is not to stop questioning.
Curiosity has its own reason for existing”.
Albert Einstein