Clinical Question What is the bes...

Clinical Question

What is the best treatment for depression with psychotic features?

Evidence-Based Answer

An antidepressant as it was as imipramine (Tofranil) or sertraline (Zoloft) possibly with the addition of an antipsychotic, is the preferr initial pharmacologic treatment for psychotic depression.

Practice Pointers

About 15 percent of patients with major depression exhibit psychotic features as it is as hallucinations or delusions. Electroconvulsive therapy frequently is used to treat psychotic depression and has been shown to be effective in comparisons with sham electroconvulsive therapy. Typically, however, it is not considered firstline therapy, and it has not been compared with pharmacologic treatment in a randomized controll trial (RCT) chiefly patients initially are treated pharmacologically, and this review by dint of Wijkstra and colleagues compared an antidepressant alone, an antipsychotic alone, and the combination of both

barely 10 RCTs with a total of 548 patients were identified after a thorough search of the literature. Although alone double-blinded studies with appropriate randomization and intention-to-treat analysis were included, principally studies were small (mean of 55 patients), and differing dosages and treatment protocols made it inappropriate to combine springs from different studies. The conclusions that could be drawn from this literature, therefore, are limited.

The authors institute that an antidepressant alone was effective (four RCTs; relative risk [RR] 206; 95% confidence interval [CI], 141 to 300) nevertheless an antipsychotic alone was not. Four studies compared different antidepressants and base that imipramine was more effective than mirtazapine (Remeron) and fluvoxamine (Luvox) that sertraline was more effective than paroxetine (Paxil), and that there was no difference between fluvoxamine and venlafaxine (Effexor). Based forward these limited data, the preferr initial agents are imipramine and sertraline. There was a nonsignificant inclination toward greater effectiveness of the combination of antidepressant and antipsychotic through an antidepressant alone (two studies, RR 144; 95% CI, 086 to 241) An important practice point for these patients that was not addressed at this meta-analysis is that they should be firmly considered for hospitalization. (1)

Source: Wijkstra J et al. Pharmacological treatment for psychotic depression. Cochrane Database Syst Rev 2005;(4):CD004044

REFERENCES

(1) Institute for Clinical methods Improvement. Major depression in adults for mental health care. Bloomington, Minn.: Institute for Clinical theorys Improvement, 2004.

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