The diagnosis of major depression with psychotic features is often missed
in patients, especially in the emergency room, a study reported in the August
Journal of Clinical Psychiatry pointed
The study, which was headed by Anthony Rothschild, M.D., chair of
psychiatry at the University of Massachusetts, included 65 inpatients at four
academic medical centers. Subjects were recruited from a larger study called
the National Institute of Mental Health Study of Pharmacotherapy of Psychotic
Depression (STOP-PD), and STOP-PD researchers had determined that all of them
had psychotic depression.
Moreover, to be in their study, Rothschild explained to Psychiatric
News, "all subjects were required to have at least one delusion,
and some also had hallucinations. The delusions were most typically somatic
delusions, paranoid delusions, delusions of guilt, delusions of poverty, and
nihilistic delusions that bad things are about to happen."
Rothschild and his colleagues then gathered each patient's hospital
records from the time preceding their enrollment in the STOP-PD study to see
what types of diagnoses he or she had received in the hospital emergency room
or hospital psychiatric unit. The 65 inpatients had received, altogether, 130
diagnoses, meaning that some had received several diagnoses. Finally
Rothschild and his team looked to see whether these 130 diagnoses had been
Over one-fourth had not, the researchers found. The three most common
misdiagnoses were major depressive disorder without psychotic features,
depression not otherwise specified, and mood disorder not otherwise specified.
Misdiagnoses made less often included delirium, anxiety disorder not otherwise
specified, and alcohol dependence.
The erroneous diagnoses were more common in emergency rooms than on
inpatient psychiatric units, and as Rothschild and his colleagues pointed out,"
It is quite striking that none of the patients with missed diagnoses
were considered to have a psychotic disorder. This finding suggests that the
physicians are missing the psychosis rather than the mood disorder. In many
cases, it may be that the physician does not miss the symptom (for example,
guilt, poverty, persecution), but does not recognize that the symptom is a
delusion. In particular, the distinction between delusional and nondelusional
guilt is frequently difficult."
These findings have important clinical implications, the researchers
believe, since major depression with psychotic features often entails
considerable morbidity and mortality, and its treatment differs from that for
major depression alone. According to the APA 2000 practice guideline on the
disorder, either an antipsychotic with an antidepressant or electroconvulsive
therapy should be used, they noted.
"As the process for DSM-V is beginning," they
continued, "it will be important to revisit the issue of whether 'major
depression with psychotic features' should be a separate illness in
DSM-V, as was recommended (but rejected) for DSM-IV, rather
than a specifier of 'major depressive disorder,' a position where it can more
easily be overlooked. The hope would be that if 'major depression with
psychotic features' were a separate illness in DSM-V, it would result
in greater awareness and more accurate diagnosis among
Meanwhile, Rothschild offered the following tips on how psychiatrists can
better detect psychotic depression:
Also, Rothschild has written a book, Clinical Manual for the Diagnosis
and Treatment of Psychotic Depression, to help physicians better diagnose
the disorder. It will be available through American Psychiatric Publishing
Inc. in November.
The study was funded by the National Institute of Mental Health.
An abstract of "Missed Diagnosis of Psychotic Depression at
Four Academic Medical Centers" is posted at<www.psychiatrist.com/abstracts/200808/080813.htm>.▪