Depression in schizophrenia

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Depression in schizophrenia

  1. 1. Depression in Schizophrenia: Symptom, Syndrome or Co-morbibidty? E. Timuçin Oral Assoc Prof of Psychiatry Bakırköy Prof Dr Mazhar Osman State Hospital for Research & Training in Neuropsychiatry Istanbul / Turkey
  2. 2. Facts about Schizophrenia  Outcome  ~15% fully recovered  ~ 85% continue to have residual and/or active sx  ~ 50% end up in hospital of day treatment  90% or more receive disability/welfare benefits or are economically dependent  75% or more are unmarried  Approximately 10% die by suicide  Twice as likely as normal controls to die from other causes
  3. 3. Facts about Schizophrenia  Culture:  Prevalence doesn‟t vary much (biological role?)  Content of delusions tends to vary cross culturally  Prevalence of schizophrenia seems to be higher in lower SES communities (cause or the result?)  May impair occupational & social functioning  Increased stress + poverty may contribute to the development
  4. 4. Schizophrenia: Course Group 3 30% have repeated episodes of illness with some impairment between episodes Group 2 25% have repeated episodes of illness with no impairment between episodes Group 1 15% have only a single episode of illness with no subsequent impairment Group 4 30% have repeated episodes of illness with gradually declining impairment between episodes
  5. 5. Schizophrenia & Related Disorders, McKenna 2003 Oxford Press
  6. 6. Schizophrenic Process 10 20 30 40 50 60 100% Functioning Age (yr) Premorbid Prodromal Progression Stabilization Relapse J. A. Lieberman.
  7. 7. DSM-IV - Schizophrenia “The characteristics of Schizophrenia involve a range of cognitive and emotional dysfunctions that include perception, inferential thinking, language and communication, behavioral monitoring, affect, fluency, and productivity of thought and speech, hedonic capacity, volition and drive, and attention” APA. DSM-IV-TR; 2000.
  8. 8. Comorbidity  Obsessive-Compulsive disorder  7.8% with schizophrenia had OCD  26% out of 50 patients met criteria for OCD  Depression  25% prevalence rate with Schizophrenia  Suicide  10% of patients commit suicide  Suicide attempts are 5 times higher than suicide rate
  9. 9. Childhood Disorders Preceding Schizophreniform Disorder (odds ratios) Childhood anxiety Depression Conduct disorder 2.5 7.4 2.5 Schizophreniform Disorder Mania 2.1 3.3 2.5 Kim-Cohen et al 2003
  10. 10. Depressive symptoms in Schizophrenia  M=F  Main indication for 40% of hospital admissions (Falloon et al, 1978)  Associated with poor outcome, personal and social adjustment  Treatment non-compliance & increased risk of suicide (Carpenter et al, 1988)
  11. 11. Pathologic Dimensions of Schizophrenia Negative Symptoms Affective flattening Alogia Avolition Anhedonia Social withdrawal Positive Symptoms Delusions Hallucinations Disorganized speech Catatonia Cognitive Deficits Attention Memory Executive functions (e.g., abstraction) Mood Symptoms Depression Anxiety Hopelessness Demoralization Stigmatization Suicidality Social/Occupational Dysfunction Work Interpersonal relationships Self-care Comorbid Substance Abuse
  12. 12. http://www.schizophrenia.com/schizpictures.html
  13. 13. Suicide & Schizophrenia  Male gender  Younger than 30  Depressive symptoms  Unemployed  Max 3 months after discharge  Unadequate treatment  Paranoid subtype  Comorbid alcohol use  Adjustment problems  Akathisia Nearly 10% of patients commit suicide:
  14. 14. Relationship Between Schizophrenia - Mood Disorders / Suicide  CINP: Mood symptoms in schizophrenia are actually a manifestation of schizophrenia rather than a discrete mood disorder (Judd, 1998)  NIMH: Lifetime prevalence 1.5% (34 out of 20,291).  Judd: 91% accompanied by mental or substance abuse disorders  NCS: 18.6% were schizophrenia without comorbid mood disorders (59% comorbid UP; 22% comorbid BP)
  15. 15. Lifetime Suicide Rates (Judd, 1996)  UP (alone) 10,4%  Schizophrenia + UP 27,5%  BP (alone) 28,5%  Schizophrenia + BP 70.6%  37% at least one suicide attempt 7.9% in nonschizophrenic population (p<0.0001)
  16. 16.  40% reported suicidal ideation  23% reported suicide attempts  6.4% died  Patients who died had lower negative symptom severity  Suspiciousness and Delusions were more severe among suicides  Paranoid subtype: elevated risk (12%)  Deficit subtype: reduced risk (1.5%) Fenton, et al. Am J Psychiatry, 1997
  17. 17. Finland National Project for Prevention of Suicide  7% of all followed-up diagnosed as schizophrenia  78% attempted in active, 40% in acute phase  64% had depressive symptoms  40% were “violent”  21% had alcohol abuse  Age distribution was equal Heilä, 1997
  18. 18. I am totally cured doctor. I am not paranoid anymore! He is trying to convince me
  19. 19. Characteristic Symptoms  Schneider: specific types of delusions and hallucinations  Bleuler: fragmented thinking, inability to relate to external world  Kraepelin: emotional dullness, avolition, loss of inner unity
  20. 20. Kraepelin: The Borders of Schizophrenia “…it is certainly possible that its borders are drawn at present in many directions too narrow, in others perhaps too wide.”
  21. 21. “Good Prognosis Schizophrenia”  Prominent affective symptoms  Acute onset  Family history of affective disorder  Good premorbid function  Presence of insight
  22. 22. Symptom Clusters in Schzophrenia Affective Depression Anxiety Aggression Dysphoria Psychomotor activation Cognitive Learning Memory Attention Executive function Language skills Negative Flattened affect Anhedonia Avolition Social withdrawal Alogia Positive Hallucinations Delusions Bizarre behavior Thought disorder Agitation
  23. 23. Depression in Schizophrenia Often been associated with  Worse outcome (5)  Impaired functioning  Personal suffering (6)  Higher rates of relapse, rehospitalization and even suicide (10% of patients) (8,11,710 11, 13) Literature on depression in schizophrenia is imprecise whether the affect, symptom, or syndrome of depression is involved.
  24. 24. Affect, Symptom, Syndrome?  Affect a mood state (happiness - sadness). Not pathological as long as situationally appropriate  Symptom a sad mood state causes a distress. An unwanted painful feeling a source of complaint.  Syndrome a complex of features includes cognitive and vegetative features pessimism, guilt, impaired concentration, lack of confidence, loss of interest / pleasure, disturbances in sleep, appetite and energy level Siris SG, Am J Psychiatry 2000; 157:1379–1389)
  25. 25. Differential Diagnosis of Depression in Schizophrenia 1. Medical/Organic Factors 2. Negative Symptoms of Schizophrenia 3. Neuroleptic-Induced Dysphoria 4. Neuroleptic-Induced Akathisia 5. Reactions to Disappointment or Stress 6. “Postpsychotic Depression” 7. Prodrome of Psychotic Relapse Siris SG, Am J Psychiatry 2000; 157:1379–1389)
  26. 26. Antipsychotic Receptor Pharmacology D1 D2 D4 5HT2A 5HT2C Musc a1 a2 H1 Haloperidole Klozapine Risperidone Quetiapine Sertindole Ziprasidone Zotepine Olanzapine
  27. 27. Objective To differentiate whether depression manifested as only a cluster of symptoms, a syndrome or a co- morbid disease in schizophrenia  97 out of 100 patients interviewed was participated Inclusion Criteria Receiving same medication >1 year Exclusion Criteria  Other psychotic diagnoses,  Co-morbidity  AD, MS or ECT treatments in the last year
  28. 28. Scales  Structured Clinical Interview for Diagnosis (SCID)  Hamilton Depression Rating Scale (HDRS)  Calgary Depression Scale for Schizophrenia (CDSS)  Positive and Negative Syndrome scale (PANSS) Definitions  Dx of MD (SCID) = „co-morbidity group‟  Scored > 8 (HDRS) + >12 (CDSS) = „syndrome group‟  Scored < 8 (HDRS) / <12 (CDSS) = „symptom group‟  Zero from all scales = „non-depression group‟
  29. 29. Patient Characteristics  47 Male (48,5%) and 50 Female (51,5%) patients.  Mean age = 38.24  59.8% single, 21,6% married and 16,5% divorced.  53,6% elementary school, 46,4% high school  82% unemployed, 15,5% still working  86,6% in middle, 11,3% in lower, 2,1% in higher economic class  10,3% living alone
  30. 30. Illness Characteristics  71,1% paranoid  16,5% undifferentiated  8,2% residual  4,1% disorganized  Age of onset: 22,3  Age of treatment: 24,5  Median of hospitalizations: 3  Mean duration of remission: 22,5 months.
  31. 31. Group Characteristics  6 patients in co-morbidity group (6.2%)  10 patients in syndrome group (10.3%)  58 patients in syndrome group (59.8%)  23 patients in non-depression group (23.7%)  No gender, education, socio-economic and marital status differences in between groups  Groups are identical in social support & SS coverage  90% of patients in co-morbid and syndrome groups are unemployed
  32. 32. Suicide rates  2 in co-morbid group (33.3%)  2 in syndrome group (20%)  19 in symptom group (32.7%)  4 in non-depressed group (17.3%)  All patients were receiving SGA  40% of symptom group & 30% of non-depressed patients were receiving clozapine  None of the patients were applied clozapine in co- morbid group
  33. 33.  100% of comorbid group  90% of syndrome group  69% of symptom group  71% of non-depressed group were diagnosed as paranoid sub-group  Depression in 1 and 2 relatives  4-6% in two groups  16.7% in co-morbid group  None in non-depressed group
  34. 34. Results  Frequency of depressive symptoms in schizophrenia is very common while it is less likely occurs as a syndrome or as an additional diagnosis.  Defining depression and the severity of depressive symptomatology is important in schizophrenia as they may play a devastating role in the course

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