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<p style="text-align: right; margin: 0pt; font-size: 10em;">See reply by <a href="/JCP/article/Pages/2012/v73n04/v73n0423.aspx" target="_top">Ruggero, et al</a>, and related article by <a href="/JCP/article/Pages/2011/v72n09/v72n0907.aspx" target="_top">Ruggero, et al</a>.</p>
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<p class="ltrs-br-ltr-br-title"><span class="bold">Artifactual Rediagnosis of Psychotic Depression as Schizophrenia</span></p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold">To the Editor: </span>Psychopathology is changed by antipsychotic-type medications, but Ruggero et al<span class="htm-cite"><a href="#ref1">1</a></span> did not account for effects of exposure to medication on diagnosis. Diagnosis of functional disorders per <span class="italic">DSM </span>requires absence of medical effects—including effects from medications—that can cause or suppress disorder criteria contents. Antipsychotic-type drugs tend to suppress symptoms, including those of depression and psychosis. As a separate matter, when given chronically these drugs can cause tardive psychosis, the symptoms of which resemble schizophrenia.<span class="htm-cite"><a href="#ref2">2</a></span> Measurable deteriorative brain changes provide further evidence of neuropsychiatric toxicity from antipsychotic drugs.<span class="htm-cite"><a href="#ref3">3</a>,<a href="#ref4">4</a></span></p>
<p class="ltrs-br-ltr-br-body-text">Ruggero et al<span class="htm-cite"><a href="#ref1">1</a></span> report that diagnoses of some patients changed from psychotic depression to schizophrenia spectrum disorders. They did not mention that such a change can result at least in part from exposure to antipsychotic drugs. If an antipsychotic drug were to suppress mood symptoms but only mitigate psychosis in a psychotic mood disorder, the apparent result on <span class="italic">DSM </span>diagnosis could be a change to a schizophrenia spectrum disorder. Induction of tardive psychosis can separately bring this same change in diagnosis. Attributing an apparent change in diagnosis to antipsychotic-type drugs may increase the clinical importance of the observations of Ruggero et al.<span class="htm-cite"><a href="#ref1">1</a></span></p>
<p class="ltrs-br-ltr-br-body-text">Others have similarly reported that patients maintained on treatment with antipsychotic drugs for conditions aside from schizophrenia are eventually rediagnosed with schizophrenia.<span class="htm-cite"><a href="#ref5">5</a></span> So it seems time to raise the bar for quality in clinical studies by requiring that psychiatric diagnosis consider both reversible and permanent effects of antipsychotic drugs and other psychotropics.</p>
<p class="ltrs-br-ltr-br-references-head"><span class="smallcaps">References</span></p>
<p class="references-references-text-1-9"><a name="ref1"></a>1. Ruggero CJ, Kotov R, Carlson GA, et al. Diagnostic consistency of major depression with psychosis across 10 years. <span class="italic">J Clin Psychiatry</span>. 2011;72(9):1207–1213. <span class="pubmed-crossref"><a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=21903033&dopt=Abstract">PubMed</a> <a href="
http://dx.doi.org/10.4088/JCP.10m06774">doi:10.4088/JCP.10m06774</a></span></p>
<p class="references-references-text-1-9"><a name="ref2"></a>2. Swartz CM. Tardive psychopathology. <span class="italic">Neuropsychobiology</span>. 1995;32(3):115–119. <span class="pubmed-crossref"><a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8544966&dopt=Abstract">PubMed</a> <a href="
http://dx.doi.org/10.1159/000119222">doi:10.1159/000119222</a></span></p>
<p class="references-references-text-1-9"><a name="ref3"></a>3. Dorph-Petersen KA, Pierri JN, Perel JM, et al. The influence of chronic exposure to antipsychotic medications on brain size before and after tissue fixation: a comparison of haloperidol and olanzapine in macaque monkeys. <span class="italic">Neuropsychopharmacology</span>. 2005;30(9):1649–1661. <span class="pubmed-crossref"><a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15756305&dopt=Abstract">PubMed</a> <a href="
http://dx.doi.org/10.1038/sj.npp.1300710">doi:10.1038/sj.npp.1300710</a></span></p>
<p class="references-references-text-1-9"><a name="ref4"></a>4. Ho BC, Andreasen NC, Ziebell S, et al. Long-term antipsychotic treatment and brain volumes: a longitudinal study of first-episode schizophrenia. <span class="italic">Arch Gen Psychiatry</span>. 2011;68(2):128–137. <span class="pubmed-crossref"><a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=21300943&dopt=Abstract">PubMed</a> <a href="
http://dx.doi.org/10.1001/archgenpsychiatry.2010.199">doi:10.1001/archgenpsychiatry.2010.199</a></span></p>
<p class="references-references-text-1-9"><a name="ref5"></a>5. Whitty P, Clarke M, McTigue O, et al. Diagnostic stability four years after a first episode of psychosis. <span class="italic">Psychiatr Serv</span>. 2005;56(9):1084–1088. <span class="pubmed-crossref"><a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16148321&dopt=Abstract">PubMed</a> <a href="
http://dx.doi.org/10.1176/appi.ps.56.9.1084">doi:10.1176/appi.ps.56.9.1084</a></span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Conrad M. Swartz, PhD, MD</span></p>
<p class="ltrs-br-ltr-br-author"><a href="
mailto:conrad.swartz@yahoo.com">
conrad.swartz@yahoo.com</a></p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Author affiliations:</span> Department of Psychiatry, Oregon Health and Science University, Portland; and Department of Psychiatry, Southern Illinois University School of Medicine, Springfield. <span class="semibold-ital">Potential conflicts of interest:</span> Dr Swartz is a stock shareholder in Abbott Laboratories, IntelGenx Technologies Corp, and Vanguard Health Care Fund. <span class="semibold-ital">Funding/support:</span> None reported.</p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="doi">doi:10.4088/JCP.11lr07621</span></p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">© Copyright 2012 Physicians Postgraduate Press, Inc.</span></p>
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