Persisting Low Use of Antipsychotics in the Treatment of Major Depressive Disorder With Psychotic Features

Carmen Andreescu, M.D.; Benoit H. Mulsant, M.D.; Catherine Peasley-Miklus, Ph.D.; Anthony J. Rothschild, M.D.; Alastair J. Flint, M.D.; Moonseong Heo, Ph.D.; Melynda Caswell, B.A.; Ellen M. Whyte, M.D.; and Barnett S. Meyers, M.D.; for the STOP-PD Study Group

Objective: Practice guidelines recommend the use of a combination of an antidepressant and an antipsychotic for the pharmacologic treatment of major depressive disorder with psychotic features (MD-Psy). We assessed the extent to which the pharmacotherapy received by patients with MD-Psy under usual care conforms to these recommendations.

Method: We assessed the pharmacotherapy received under usual care conditions by 100 patients with MD-Psy prior to enrollment in STOP-PD (Study of the Pharmacotherapy of Psychotic Depression), a 12-week randomized, controlled trial comparing olanzapine plus sertraline to olanzapine plus placebo. Our assessment took place from January 2003 to May 2004. The strength of antidepressant trials was rated using the Antidepressant Treatment History Form (ATHF). The strength of antipsychotic trials or combinations of antidepressants and antipsychotics was rated using a modified version of the ATHF. We also determined whether the strength of antipsychotic or combination trials was associated with age, the duration of the current depressive episode, medical burden, cognitive status, or the severity of depressive or psychotic symptoms.

Results: Most patients with MD-Psy were treated with antidepressants (N = 82, 82%) or antipsychotics (N = 65, 65%). About half of the patients (N = 48, 48%) received therapeutic doses of an antidepressant; 10% (N = 10) received an intermediate dose of an antipsychotic, and 6% (N = 6) received a high dose. Overall, only 5% (N = 5) received a combination of an adequate dose of an antidepressant and a high dose of an antipsychotic. The strength of both antipsychotic trials (p = .021) and combination trials (p = .039) was significantly associated only with a longer duration of the current depressive episode.

Conclusions: These findings show a persisting low use of antipsychotics in the treatment of MD-Psy. Given the high morbidity rates associated with MD-Psy, it is important to continue to educate clinicians regarding its identification and treatment.

Clinical Trials Registration: ClinicalTrials.gov identifier NCT00056472.

(J Clin Psychiatry 2007;68:194-200)

Received March 23, 2006; accepted July 17, 2006. From the Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, Pa. (Drs. Andreescu, Mulsant, and Whyte); Centre for Addiction and Mental Health (Dr. Mulsant), Department of Psychiatry, University of Toronto (Drs. Mulsant and Flint), Toronto General Research Institute, University Health Network, and Geriatric Program and Research Institute, Toronto Rehabilitation Institute (Dr. Flint), Toronto, Ontario, Canada; the Department of Psychiatry, University of Massachusetts Medical School and UMass Memorial Health Care, Worcester, Mass. (Dr. Rothschild); and Department of Psychiatry, Weill Medical College of Cornell University, New York, N.Y., and New York Presbyterian Hospital-Westchester, White Plains, N.Y. (Drs. Peasley-Miklus, Heo, and Meyers and Ms. Caswell).

This research was supported in part by U.S. Public Health Service grants MH069430, MH48512, MH62446, MH62518, MH62565, M01-RR000056, and MH67710 from the National Institute of Mental Health. Eli Lilly and Pfizer provided medications for the STOP-PD trial.

Financial disclosure appears at the end of the article.

Corresponding author and reprints: Benoit H. Mulsant, M.D., #3011, CAMH, 1001 Queen St., Toronto, ON, Canada M6J 1H4(e-mail: benoit_mulsant@camh.net).