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Rasit Tahsin

duygudurum
merkezi

Depression in Schizophrenia:
Symptom, Syndrome or
Co-morbidity?
E. Timuçin Oral
Assoc Prof of Psychiatry

Bakırköy Prof Dr Mazhar Osman State Hospital for Research


& Training in Neuropsychiatry
Istanbul / Turkey
Facts about Schizophrenia

 Outcome
 ~15% fully recovered
 ~ 85% have residual and/or active sx
 90% or more are economically dependent
 75% or more are unmarried
 ~ 10% die by suicide
 Mortality 2x more than healthy controls
Simple Courses
38%

Undulating Courses
58%

Atypical Courses
4%

McKenna 2003
DSM-IV - Schizophrenia

“The characteristics of Schizophrenia


involve a range of cognitive and
emotional dysfunctions that include
perception, inferential thinking, language
and communication, behavioral
monitoring, affect, fluency, and
productivity of thought and speech,
hedonic capacity, volition and drive, and
attention”
APA. DSM-IV-TR; 2000.
Symptom Clusters in Schzophrenia

Positive Negative Cognitive Affective

Hallucinations Flattened affect Learning Depression


Delusions Anhedonia Memory Anxiety
Bizarre Avolition Attention Aggression
behavior Social withdrawal Executive Dysphoria
Thought Alogia function Psychomotor
disorder Language skills activation
Agitation
Pathological Dimensions of
Schizophrenia
Positive Symptoms Negative Symptoms
Delusions Affective flattening
Hallucinations Alogia
Disorganized speech Avolition
Catatonia Anhedonia
Social withdrawal

Social/Occupational Dysfunction
Work
Interpersonal relationships
Self-care Mood Symptoms
Depression
Cognitive Deficits Anxiety
Attention Hopelessness
Memory Demoralization
Executive functions Stigmatization
(e.g., abstraction) Comorbid Substance Abuse Suicidality
Good Prognosis in Schizophrenia (?)

 Prominent affective symptoms


 Acute onset
 Family history of affective disorder
 Good premorbid function
 Presence of insight
Depressive symptoms in
Schizophrenia
 M=F
 Main indication for 40% of hospital admissions
(Falloon et al, 1978)
 Associated with poor outcome, personal and
social adjustment
 Treatment non-compliance & increased risk of
suicide
(Carpenter et al, 1988)
Comorbidity
 Obsessive-Compulsive disorder
 7.8% with schizophrenia had OCD
 26% out of 50 patients met criteria for OCD

 Depression
 25% prevalence rate with Schizophrenia

 Suicide
 10% of patients commit suicide
 Suicide attempts are 5 times higher than suicide rate
Lifetime Suicide Rates

 UP (alone) 10,4%
 Schizophrenia + UP 27,5%
 BP (alone) 28,5%
 Schizophrenia + BP 70.6%
 37% at least one suicide attempt
7.9% in nonschizophrenic population (p<0.0001)

(Judd, 1996)
 40% reported suicidal ideation
 23% reported suicide attempts
 6.4% died
 Patients who died had lower negative
symptom severity
 Suspiciousness and Delusions were more
severe among suicides
 Paranoid subtype: elevated risk (12%)
 Deficit subtype: reduced risk (1.5%)

Fenton, et al. Am J Psychiatry, 1997


Relationship Between
Schizophrenia - Mood Disorders / Suicide

 CINP: Mood symptoms in schizophrenia are actually


a manifestation of schizophrenia rather than a
discrete mood disorder
 NIMH: Lifetime prevalence 1.5% (34 out of 20,291).
 NCS: 18.6% were schizophrenia without comorbid
mood disorders (59% comorbid UP; 22% comorbid BP)

(Judd, 1998)
Depression in Schizophrenia
Often been associated with
 Worse outcome (Falloon et al 1978)
 Impaired functioning
 Personal suffering (Siris, 2000)
 Higher rates of relapse, rehospitalization and
even suicide (10% of patients)
(Mandel et al 1982; Roy et al 1983; Birchwood et al 1993;
Caldwell-Gottesman 1990; Fenton et al 1997)
 Literature on depression in schizophrenia is
imprecise whether the affect, symptom, or syndrome
of depression is involved.
Affect, Symptom, Syndrome?
 Affect a mood state (happiness - sadness). Not
pathological as long as situationally appropriate

 Symptom a sad mood state causes a distress. An


unwanted painful feeling a source of complaint.

 Syndrome a complex of features includes


cognitive and vegetative features
pessimism, guilt, impaired concentration, lack of confidence, loss of
interest / pleasure, disturbances in sleep, appetite and energy level

Siris SG, Am J Psychiatry 2000; 157:1379–1389


Objective
To differentiate whether depression manifested as
only a cluster of symptoms, a syndrome or a co-
morbid disease in schizophrenia (DSM-IV)

 97 out of 100 patients interviewed was


participated

Inclusion Criteria
Receiving same medication >1 year

Exclusion Criteria
 All other psychotic diagnoses,
 All other medical and psychiatric diagnosis
Scales
 Structured Clinical Interview for Diagnosis (SCID)
 Hamilton Depression Rating Scale (HDRS)
 Calgary Depression Scale for Schizophrenia (CDSS)
 Positive and Negative Syndrome scale (PANSS)

Definitions
 Dx of MD (SCID) = ‘co-morbidity group’
 Scored > 8 (HDRS) + >12 (CDSS) = ‘syndrome group’
 Scored < 8 (HDRS) / <12 (CDSS) = ‘symptom group’
 Scored ≤ 2 (HDRS + CDSS) = ‘non-depression group’
Patient Characteristics

 47 Male (48,5%) and 50 Female (51,5%) patients.


 Mean age = 38.24
 59.8% single, 21,6% married and 16,5% divorced.
 53,6% elementary school, 46,4% high school

 82% unemployed, 15,5% still working

 86,6% in middle, 11,3% in lower, 2,1% in higher


economic class

 10,3% living alone


Illness Characteristics

 71,1% paranoid
 16,5% undifferentiated
 8,2% residual
 4,1% disorganized

 Age of onset: 22,3


 Age of treatment: 24,5

 Median of prvious hospitalizations: 3


 Mean duration of remission: 22,5 months.
Group Characteristics

 6 patients in co-morbidity group (6.2%)


 10 patients in syndrome group (10.3%)
 58 patients in symptome group (59.8%)
 23 patients in non-depression group (23.7%)

 No gender, education, socio-economic and marital


status differences in between groups

 Groups are identical in social support & SS coverage

 90% of patients in co-morbid and syndrome groups


are unemployed
Symp Synd Comorbidity Non-Dep p

CDSS 1,90 9,60 12,17 0,04 0,001


HAMD 5,21 14,80 18,67 0,09 0,001

PANS-T 59,57 62,00 62,33 43,04 0,001


Positive 10,95 10,40 12,33 8,87 NS
Negative 20,50 16,70 16,67 15,13 0,01

Correlation of Depression Scales with PANNS-T


r = 0,134; p = 0,190 CDSS
*r = 0,367; p < 0,001 HAMD

*PANNS General Sx subscale highly and significantly correlated with HAMD


Symp Synd Comorbidity Non-Dep p

CDSS 1,90 9,60 12,17 0,04 0,001


HAMD 5,21 14,80 18,67 0,09 0,001

PANS-T 59,57 62,00 62,33 43,04 0,001


Positive 10,95 10,40 12,33 8,87 NS
Negative 20,50 16,70 16,67 p<0.04 15,13 0,01

Correlation of Depression Scales with PANNS-T


r = 0,134; p = 0,190 CDSS
*r = 0,367; p < 0,001 HAMD

*PANNS General Sx subscale highly and significantly correlated with HAMD


Symp Synd Comorbidity Non-Dep p

CDSS 1,90 9,60 12,17 0,04 0,001


HAMD 5,21 14,80 18,67 0,09 0,001

PANS-T 59,57 62,00 62,33 43,04 0,001


Positive 10,95 10,40 12,33 8,87 NS
Negative 20,50 16,70 16,67 p<0.04 15,13 0,01
p<0.001

Correlation of Depression Scales with PANNS-T


r = 0,134; p = 0,190 CDSS
*r = 0,367; p < 0,001 HAMD

*PANNS General Sx subscale highly and significantly correlated with HAMD


 100% of comorbid group
 90% of syndrome group
 69% of symptom group
 71% of non-depressed group
were in paranoid sub-group

 Depression in 1° and 2° relatives


 4-6% in two groups
 16.7% in co-morbid group
 None in non-depressed group
http://www.schizophrenia.com/schizpictures.html
Suicide rates

 2 in co-morbid group (33.3%)


 2 in syndrome group (20%)
 19 in symptom group (32.7%)
 4 in non-depressed group (17.3%)

Treatment

 75 (78,9%) of all patients were receiving SGA


 40% of symptom group & 30% of non-depressed
patients were receiving clozapine
 None of the patients were applied clozapine in co-
morbid group
Differential Diagnosis of
Depression
in Schizophrenia
 Medical/Organic Factors
 Negative Symptoms of Schizophrenia
3. Neuroleptic-Induced Dysphoria
 Neuroleptic-Induced Akathisia
 Reactions to Disappointment or Stress
 “Postpsychotic Depression”
 Prodrome of Psychotic Relapse

Siris SG, Am J Psychiatry 2000; 157:1379–1389)


Antipsychotic Treatment & Depression
Antipsychotic Receptor Pharmacology
D1
Haloperidole Klozapine Olanzapine Quetiapine D2
D4
5HT2A
5HT2C
Musc
a1
a2
H1

Risperidone Sertindole Ziprasidone Zotepine


Results
 Frequency of depressive symptoms is common in
schizophrenia; although it less likely manifests as
a syndrome or as an additional diagnosis

 Defining depression and the severity of


symptoms is important as they may play a
devastating role in the course

 Positive symptoms must be taken into


consideration seriously as they may be the
“cause” of depression.
I am totally cured He is trying to
doctor. I am not convince me
paranoid anymore!