How Long Should Patients With Psychotic Depression Stay on the Antipsychotic Medication? [CME]
J Clin Psychiatry 2003;64(4):390-396
© Copyright 2014 Physicians Postgraduate Press, Inc.
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Background: Patients who have major depression
with psychotic features have greater morbidity and mortality than
patients with nonpsychotic major depression. In particular,
relapse and recurrence have been reported to occur more
frequently in patients with psychotic depression than
nonpsychotic depression. Despite the frequent relapse and
recurrence in major depression with psychotic features, there are
few studies of the efficacy of continuation and maintenance
Method: Forty patients with a diagnosis of
unipolar DSM-III-R major depression with psychotic features were
treated with fluoxetine and perphenazine for 5 weeks after
granting written informed consent. The patients who responded to
treatment continued to receive the combination for an additional
3 months. If a patient was stable for 4 months on treatment with
the combination, the patient was then gradually tapered off
perphenazine treatment. For patients who exhibited impending
relapse, perphenazine was restarted. Impending relapse was
defined as any of the following: (1) symptoms meeting DSM-IV
criteria for major depressive disorder (with or without psychotic
features), (2) a total score of >= 17 on the HAM-D, or (3) the
presence of any psychotic symptoms. After 1 year of taking
fluoxetine, patients were tapered off fluoxetine treatment. Data
were gathered from 1992 to 1997.
Results: Thirty patients responded to the
initial 5 weeks of treatment with perphenazine and fluoxetine.
After taper of perphenazine following 4 months of treatment with
fluoxetine and perphenazine, 22 (73%) of the 30 patients
exhibited no signs of relapse over the next 11 months (8 months
of fluoxetine monotherapy followed by a taper of fluoxetine and 3
additional months of assessment). Patients who showed signs of
relapse after taper of the antipsychotic were more likely to have
had a longer duration of the current episode and a history of
more frequent past episodes and were more likely to be younger
(under the age of 30 years).
Conclusion: The data from this study suggest
that a majority of patients who have major depression with
psychotic features do not require treatment with antipsychotic
medication for more than 4 months.