Missed Diagnosis of Psychotic Depression at 4 Academic Medical Centers
J Clin Psychiatry 2008;69(8):1293-1296
© Copyright 2014 Physicians Postgraduate Press, Inc.
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Background: Major depressive disorder
with psychotic features (psychotic depression),
though occurring relatively frequently in the
general population, is a commonly missed
Objective: To ascertain accuracy of
diagnosis of psychotic depression among inpatients at
4 academic medical centers and explore whether presenting symptoms, treatment setting,
and physician's level of training affect the accuracy
Method: The medical records of 65
patients who met DSM-IV criteria for psychotic
depression following systematic assessment were
analyzed to ascertain the concordance between
chart diagnoses and research diagnoses arrived at
using the Structured Clinical Interview for
DSM-IV. The patients were participants in the
National Institute of Mental Health Study of
Pharmacotherapy of Psychotic Depression, conducted
from December 28, 2002, through June 18, 2004, at
4 academic medical centers. For each patient's hospital visit, separate standardized data forms
were completed on the basis of each physician's
assessment of the patient prior to screening for
the study. Hospital records from the emergency
room and from admission to psychiatric units were
reviewed. Among these 65 patients, 130 chart diagnoses had been made.
Results: Psychotic depression had not
been diagnosed prior to research assessments for
27% of the 130 diagnoses in our sample. The 3 most common diagnoses assigned to patients
meeting research criteria for psychotic depression
were major depressive disorder without psychotic
features, depression not otherwise specified, and mood disorder not otherwise specified. Failure
to identify psychotic depression was more likely when symptoms of depressed mood,
hallucinations, or delusions were not noted in the
medical record (all p < .005). The accuracy of
diagnoses was greater on inpatient units than in
emergency rooms (chi2 = 7.64, p < .01).
Conclusion: The diagnosis of psychotic
depression is frequently missed in emergency room and inpatient settings. The findings of this
study are sobering given the serious morbidity and
mortality of psychotic depression and the implications for treatment if an inaccurate diagnosis
Trial Registration: clinicaltrials.gov