depression in schizophrenia
DESCRIPTION
PsychiatryTRANSCRIPT
Depression in Schizophrenia: Depression in Schizophrenia: Symptom, Syndrome Symptom, Syndrome
or Co-morbibidty?or Co-morbibidty?
E. Timuçin OralE. Timuçin OralAssoc Prof of PsychiatryAssoc Prof of Psychiatry
Bakırköy Prof Dr Mazhar Osman State Hospital Bakırköy Prof Dr Mazhar Osman State Hospital for Research & Training in Neuropsychiatry for Research & Training in Neuropsychiatry
Istanbul / TurkeyIstanbul / Turkey
Facts about SchizophreniaFacts about Schizophrenia
OutcomeOutcome ~~15% fully recover15% fully recovereded ~~ 85% continue to have residual and/or active 85% continue to have residual and/or active ssxx ~~ 50% end up in hospital of day treatment 50% end up in hospital of day treatment 90% or more receive disability/welfare benefits or are 90% or more receive disability/welfare benefits or are
economically dependenteconomically dependent 75% or more are unmarried75% or more are unmarried Approximately 10% die by suicideApproximately 10% die by suicide Twice as likely as normal controls to die from other Twice as likely as normal controls to die from other
causescauses
Facts about SchizophreniaFacts about Schizophrenia
Culture:Culture: Prevalence doesn’t vary much Prevalence doesn’t vary much ((biological rolebiological role?)?)
Content of delusions tends to vary cross culturallyContent of delusions tends to vary cross culturally
Prevalence Prevalence of sof schizophrenia seems to be higher in chizophrenia seems to be higher in lower SES communitieslower SES communities (cause or the result?) (cause or the result?)
MMay impair occupationalay impair occupational & & social social functioning functioning Increased stress Increased stress ++ poverty may contribute to the poverty may contribute to the
development development
SchizophreniaSchizophrenia: : CourseCourse
Group 330% have repeated episodes of illness with some impairment between episodes
Group 225% have repeated episodes of illness with no impairment between episodes
Group 115% have only a single episode of illness with no subsequent impairment
Group 430% have repeated episodes of illness with gradually declining impairment between episodes
Schizophrenia & Schizophrenia & Related Disorders, Related Disorders,
McKenna 2003 McKenna 2003 Oxford PressOxford Press
Schizophrenic ProcessSchizophrenic Process
1010 2020 3030 4040 5050 6060
100100%%
FunctioningFunctioning
AgeAge ( (yryr))
Premorbid
Prodromal
Progression
StabilizationRelapse
J. A. Lieberman.
DSM-IV DSM-IV -- Schizophrenia Schizophrenia
““The characteristics of Schizophrenia The characteristics of Schizophrenia involve a range of cognitive and involve a range of cognitive and emotional dysfunctionsemotional dysfunctions that include that include perception, inferential thinking, language perception, inferential thinking, language and communication, behavioral and communication, behavioral monitoring, monitoring, affectaffect, fluency, and , fluency, and productivity of thought and speech, productivity of thought and speech, hedonic capacityhedonic capacity, volition and drive, and , volition and drive, and attention” attention”
APA. DSM-IV-TR; 2000.
ComorbidityComorbidity
Obsessive-Compulsive disorderObsessive-Compulsive disorder 7.8% with schizophrenia had OCD7.8% with schizophrenia had OCD 26% out of 50 patients met criteria for OCD26% out of 50 patients met criteria for OCD
DepressionDepression 25% prevalence rate with Schizophrenia25% prevalence rate with Schizophrenia
SuicideSuicide 10% of patients commit suicide10% of patients commit suicide Suicide attempts are 5 times higher than suicide rateSuicide attempts are 5 times higher than suicide rate
CChildhood hildhood DDisorders isorders PPreceding receding SSchizophreniform chizophreniform DDisorder isorder (odds ratios)(odds ratios)
Childhood anxietyChildhood anxiety
DepressionDepression
Conduct disorderConduct disorder
2.5 2.5
7.47.4
2.52.5
SchizophreniformSchizophreniformDDisorderisorder
ManiaMania
2.12.1
3.33.3
2.52.5
Kim-Cohen et al 2003
Depressive symptoms in Depressive symptoms in SchizophreniaSchizophrenia
M=FM=F
Main indication for 40% of hospital admissions Main indication for 40% of hospital admissions
(Falloon et al, 1978)(Falloon et al, 1978)
Associated with poor outcome, personal and Associated with poor outcome, personal and social adjustment social adjustment
Treatment non-compliance & increased risk of Treatment non-compliance & increased risk of suicide suicide (Carpenter et al, 1988)(Carpenter et al, 1988)
Pathologic Dimensions of Pathologic Dimensions of SchizophreniaSchizophrenia
Negative SymptomsNegative SymptomsAffective flatteningAffective flatteningAlogiaAlogiaAvolitionAvolitionAnhedoniaAnhedoniaSocial withdrawalSocial withdrawal
Positive SymptomsPositive SymptomsDelusionsDelusionsHallucinationsHallucinationsDisorganized speechDisorganized speechCatatoniaCatatonia
Cognitive DeficitsCognitive DeficitsAttentionAttentionMemoryMemoryExecutive functionsExecutive functions(e.g., abstraction)(e.g., abstraction)
Mood SymptomsMood SymptomsDepressionDepressionAnxietyAnxietyHopelessnessHopelessnessDemoralizationDemoralizationStigmatizationStigmatizationSuicidalitySuicidality
Social/Occupational DysfunctionSocial/Occupational DysfunctionWorkWork
Interpersonal relationshipsInterpersonal relationshipsSelf-careSelf-care
Comorbid Substance AbuseComorbid Substance Abuse
http://www.schizophrenia.com/schizpictures.html
Suicide & SchizophreniaSuicide & Schizophrenia
Male genderMale gender
Younger than Younger than 3030
DDepresepresssiiveve symptomssymptoms
UnemployedUnemployed
Max 3 months after Max 3 months after discharge discharge
Unadequate treatmentUnadequate treatment
PParanoid aranoid subtypesubtype
CComorbid alomorbid alccoohoholl use use
Adjustment problemsAdjustment problems
AAkatkathhiissiiaa
Nearly 10% of patients commit suicide:Nearly 10% of patients commit suicide:
Relationship Between Relationship Between
Schizophrenia - Mood Disorders / Suicide Schizophrenia - Mood Disorders / Suicide
CINP: Mood symptoms in schizophrenia are actually CINP: Mood symptoms in schizophrenia are actually a manifestation of schizophrenia rather than a a manifestation of schizophrenia rather than a discrete mood disorder (Judd, 1998)discrete mood disorder (Judd, 1998)
NIMH: Lifetime prevalence 1.5% (34 out of 20,291). NIMH: Lifetime prevalence 1.5% (34 out of 20,291).
Judd: 91% accompanied by mental or substance Judd: 91% accompanied by mental or substance abuse disordersabuse disorders
NCS: 18.6% were schizophrenia without comorbid NCS: 18.6% were schizophrenia without comorbid mood disordersmood disorders ((59% comorbid UP; 22% comorbid BP)59% comorbid UP; 22% comorbid BP)
Lifetime Suicide RatesLifetime Suicide Rates (Judd, 1996)(Judd, 1996)
UP (alone)UP (alone) 10,4%10,4% Schizophrenia + UPSchizophrenia + UP 27,5% 27,5% BP (alone)BP (alone) 28,5%28,5% Schizophrenia + BPSchizophrenia + BP 70.6%70.6% 37% at least one suicide attempt 37% at least one suicide attempt
7.9% in nonschizophrenic population (7.9% in nonschizophrenic population (p<0.0001p<0.0001))
40% reported suicidal ideation40% reported suicidal ideation 23% reported suicide attempts23% reported suicide attempts 6.4% died6.4% died
Patients who died had lower negative Patients who died had lower negative symptom severity symptom severity
Suspiciousness and Delusions were more Suspiciousness and Delusions were more severe among suicidessevere among suicides
Paranoid subtype: elevated risk (12%)Paranoid subtype: elevated risk (12%) Deficit subtype: Deficit subtype: reduced risk (1.5%) reduced risk (1.5%)
Fenton, et al. Am J Psychiatry, 1997Fenton, et al. Am J Psychiatry, 1997
FinFinlandland National Project for National Project for Prevention of SuicidePrevention of Suicide
77% of all followed% of all followed-up diagnosed as -up diagnosed as schschizoizophphrenreniaia
7878% attempted in active, 4% attempted in active, 400% in acute phase % in acute phase
6464% had d% had depresepresssiive symptoms ve symptoms
4040% were “violent” % were “violent”
2121% had a% had allccoohohol l abuseabuse
Age distribution was equalAge distribution was equal
Heilä, 1997Heilä, 1997
I am totally cured doctor. I am not paranoid anymore!
He is trying to convince
me
Characteristic SymptomsCharacteristic Symptoms
Schneider: specific types of delusions Schneider: specific types of delusions and hallucinationsand hallucinations
Bleuler: fragmented thinking, inability Bleuler: fragmented thinking, inability to relate to external worldto relate to external world
Kraepelin: emotional dullness, Kraepelin: emotional dullness, avolition, loss of inner unityavolition, loss of inner unity
Kraepelin: Kraepelin: The Borders of SchizophreniaThe Borders of Schizophrenia
““……it is certainly possible that its borders it is certainly possible that its borders are drawn at present in many directions are drawn at present in many directions too narrow, in others perhaps too wide.too narrow, in others perhaps too wide.””
““Good Prognosis Schizophrenia”Good Prognosis Schizophrenia”
Prominent affective symptomsProminent affective symptoms Acute onsetAcute onset Family history of affective disorderFamily history of affective disorder Good premorbid function Good premorbid function Presence of insightPresence of insight
Symptom Clusters in SchzophreniaSymptom Clusters in Schzophrenia
AffectiveAffective
DepressionDepression
AnxietyAnxiety
AggressionAggression
DysphoriaDysphoria
PsychomotorPsychomotoractivationactivation
CognitiveCognitive
LearningLearning
MemoryMemory
AttentionAttention
Executive Executive functionfunction
Language skillsLanguage skills
NegativeNegative
Flattened affectFlattened affect
AnhedoniaAnhedonia
AvolitionAvolition
Social Social withdrawalwithdrawal
AlogiaAlogia
PositivePositive
HallucinationsHallucinations
DelusionsDelusions
Bizarre Bizarre behaviorbehavior
Thought Thought disorderdisorder
AgitationAgitation
Depression in SchizophreniaDepression in Schizophrenia
Often been associated with Often been associated with Worse outcome (5)Worse outcome (5) Impaired functioningImpaired functioning Personal suffering (6)Personal suffering (6) Higher rates of relapse, rehospitalization and Higher rates of relapse, rehospitalization and
even suicide (10% of patients) even suicide (10% of patients) (8,11,710 11, 13)(8,11,710 11, 13)
Literature on depression in schizophrenia is Literature on depression in schizophrenia is imprecise whether the affect, symptom, or imprecise whether the affect, symptom, or syndrome of depression is involved. syndrome of depression is involved.
Affect, Symptom, Syndrome?Affect, Symptom, Syndrome?
AffectAffect a mood state (happiness - sadness). Not a mood state (happiness - sadness). Not pathological as long as situationally appropriate pathological as long as situationally appropriate
SymptomSymptom a sad mood state causes a distress. An a sad mood state causes a distress. An unwanted painful feeling a source of complaint. unwanted painful feeling a source of complaint.
SyndromeSyndrome a complex of features includes a complex of features includes cognitive and vegetative features cognitive and vegetative features
pessimism, guilt, impaired concentration, lack of confidence, loss of pessimism, guilt, impaired concentration, lack of confidence, loss of interest / pleasure, disturbances in sleep, appetite and energy levelinterest / pleasure, disturbances in sleep, appetite and energy level
Siris SG, Am J Psychiatry 2000; 157:1379–1389)
Differential Diagnosis of Differential Diagnosis of DepressionDepression
in Schizophreniain Schizophrenia
1.1. Medical/Organic FactorsMedical/Organic Factors
2.2. Negative Symptoms of SchizophreniaNegative Symptoms of Schizophrenia
3.3. Neuroleptic-Induced DysphoriaNeuroleptic-Induced Dysphoria
4.4. Neuroleptic-Induced AkathisiaNeuroleptic-Induced Akathisia
5.5. Reactions to Disappointment or StressReactions to Disappointment or Stress
6.6. ““Postpsychotic Depression”Postpsychotic Depression”
7.7. Prodrome of Psychotic RelapseProdrome of Psychotic Relapse
Siris SG, Am J Psychiatry 2000; 157:1379–1389)
Antipsychotic Receptor PharmacologyAntipsychotic Receptor Pharmacology
D1D1D2D2D4D45HT2A5HT2A5HT2C5HT2CMuscMusca1a1a2a2H1H1
HaloperidolHaloperidolee KKlozapinlozapinee
RisperidonRisperidonee
QuetiapineQuetiapine
SertindoSertindolele ZiprasidonZiprasidonee ZotepinZotepinee
OlanzapinOlanzapinee
ObjectiveObjectiveTo differentiate whether depression manifested as To differentiate whether depression manifested as only a cluster of symptoms, a syndrome or a co-only a cluster of symptoms, a syndrome or a co-morbid disease in schizophreniamorbid disease in schizophrenia
97 97 out of out of 100 patients 100 patients interviewed was interviewed was participateparticipatedd
Inclusion CriteriaInclusion CriteriaReceiving same medication Receiving same medication >1 >1 yearyear
Exclusion CriteriaExclusion Criteria Other psychotic diagnoses, Other psychotic diagnoses, Co-morbidity Co-morbidity AADD, MS or ECT treatment, MS or ECT treatmentss in the last year in the last year
Scales Scales Structured Clinical Interview for Diagnosis (SCID)Structured Clinical Interview for Diagnosis (SCID) Hamilton Depression Rating Scale (HDRS) Hamilton Depression Rating Scale (HDRS) Calgary Depression Scale for Schizophrenia (CDSS)Calgary Depression Scale for Schizophrenia (CDSS) Positive and Negative Syndrome scale (PANSS)Positive and Negative Syndrome scale (PANSS)
DefinitionsDefinitions
Dx of MD Dx of MD ((SCIDSCID)) = ‘co-morbidity group’ = ‘co-morbidity group’ ScoreScoredd > > 8 8 ((HDRSHDRS)) ++ >>12 12 ((CDSSCDSS)) = ‘syndrome group’ = ‘syndrome group’ ScoreScoredd < < 8 8 ((HDRSHDRS)) // < <12 12 ((CDSSCDSS)) = ‘symptom group’ = ‘symptom group’ Zero from all scales = ‘non-depression group’Zero from all scales = ‘non-depression group’
Patient CharacteristicsPatient Characteristics
47 Male (48,5%) and 50 Female (51,5%) patients. 47 Male (48,5%) and 50 Female (51,5%) patients. Mean age = 38.24Mean age = 38.24 59.8% single59.8% single,, 21,6% married and 16,5% divorced. 21,6% married and 16,5% divorced. 53,6% 53,6% elementary school, elementary school, 46,4% high school 46,4% high school
82% unemployed82% unemployed, , 15,5% still working15,5% still working
86,6% 86,6% in in middlemiddle, 1, 11,3% 1,3% in in lowerlower, , 2,1% 2,1% in in higherhigher economic classeconomic class
10,3% living alone 10,3% living alone
IllnessIllness Characteristics Characteristics
71,1% paranoid71,1% paranoid 16,5% undifferentiated16,5% undifferentiated 8,2% residual8,2% residual 4,1% disorganized4,1% disorganized
AAge of onsetge of onset:: 22,3 22,3 AAge of treatmentge of treatment:: 24,524,5
Median Median of of hospitalizationhospitalizations:s: 3 3 MMean duration of remissionean duration of remission:: 22,5 months. 22,5 months.
Group CharacteristicsGroup Characteristics
6 patients in co-morbidity group (6.2%)6 patients in co-morbidity group (6.2%) 10 patients in syndrome group (10.3%) 10 patients in syndrome group (10.3%) 58 patients in syndrome group (59.8%)58 patients in syndrome group (59.8%) 23 patients in non-depression group (23.7%)23 patients in non-depression group (23.7%)
No gender, education, socio-economic and marital No gender, education, socio-economic and marital status differences in status differences in between between groupsgroups
GGroups roups are are identical in social support identical in social support && SS SS coveragecoverage
90% 90% of of patients in co-morbid patients in co-morbid and and syndrome groupsyndrome groups s are are unemployed unemployed
Suicide ratesSuicide rates
2 in co-morbid group (33.3%)2 in co-morbid group (33.3%) 2 in syndrome group (20%)2 in syndrome group (20%) 19 in symptom group (32.7%)19 in symptom group (32.7%) 4 in non-depressed group (17.3%)4 in non-depressed group (17.3%)
All patients were All patients were receivingreceiving SGA SGA 40% of symptom group40% of symptom group & & 30% of non-depressed 30% of non-depressed
patients were receiving clozapinepatients were receiving clozapine None of the patients were applied clozapine in co-None of the patients were applied clozapine in co-
morbid groupmorbid group
100% of comorbid group100% of comorbid group 90% of syndrome group 90% of syndrome group 69% of symptom group 69% of symptom group 71% of non-depressed group 71% of non-depressed group
were diagnosed as paranoid sub-were diagnosed as paranoid sub-groupgroup
Depression in 1Depression in 1°° andand 2 2°° relatives relatives 4-6% in two groups4-6% in two groups 16.7% in co-morbid group16.7% in co-morbid group None in non-depressed groupNone in non-depressed group
ResultsResults
Frequency of depressive symptoms in Frequency of depressive symptoms in schizophrenia is very common while it is less schizophrenia is very common while it is less likely occurs as a syndrome or as an additional likely occurs as a syndrome or as an additional diagnosis. diagnosis.
Defining depression and the severity of Defining depression and the severity of depressive symptomatology is important in depressive symptomatology is important in schizophrenia as they may play a devastating role schizophrenia as they may play a devastating role in the coursein the course