Evidence-based Treatment of Psychotic Depression. Gregory W. Dalack, MD June 22, 2006. The Practice of EBM. Step 1: Asking an answerable question Step 2: Tracking down the best evidence to answer that question
Evidence-based Treatment of Psychotic Depression
Gregory W. Dalack, MD
June 22, 2006
For patients with psychotic depression...
...is antidepressant treatment alone...
...when compared to antidepressant plus antipsychotic treatment…
...result in greater improvement of depressive/psychotic symptoms?
ACP Medicine (2006): “Depression with associated psychotic features must be treated with an antidepressant and an antipsychotic medication.”70
Treatment of Psychiatric Disorders (2001): “The relative refractoriness of psychotic depression to antidepressant treatment alone suggests that psychotic symptoms require additional specific treatments. In a prospective study, Spiker et al. (1985) demonstrated superior efficacy for treatment of psychoticdepression using a combination of an antidepressant and an antipsychotic drug compared with monotherapy with an antidepressant.”
Review Article (J Clin Psychiatry, suppl. 2003)
Abstr: “Data support the use of antipsychotics in combination with antidepressants for major depression with psychotic features, but other treatments may have great or greater efficacy for the disorder”
“atypical antipsychotics alone may be effective for psychotic depression….Olanzapine has also been found successful monotherapy in psychotic depression…substantial improvement in symptoms of psychotic depression in a patient…and a case report in Germany….”
“The drug treatments that have been typically been effective for psychotic depression include combination of antidepressants with antipsychotics”
Supplement supported by Eli Lilly and company
Cochrane Review: Wijkstra et al, (16-Nov-2005)
Plain language summary: The combination of an antidepressant with an antipsychotic may not be more effective than an antidepressant alone, however, combination therapy may be more effective than an antipsychotic alone.Starting with the combination of an antidepressant and an antipsychotic, as well as starting with an antidepressant alone and adding an antipsychotic if the patient does not respond, both appear to be appropriate options for patients with psychotic depression. Clinically, the balance between risks and benefits suggests that initial antidepressant monotherapy should be the preferred option for many patients. Antipsychotic monotherapy is not an appropriate treatment strategy. The general lack of available data limits confidence in the conclusions drawn.