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Treating a Major Depressive Episode with Psychotic Features

The following treatment guidelines are meant as a reference tool only, and are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

 

Step 1: Combine an antipsychotic (option a) with an antidepressant (option b). However, in situations where an individual is reluctant to start with more than one medication, starting with the antidepressant alone (option b) is acceptable [ref]):

  1. Start an antipsychotic.
    • If choosing a Typical Antipsychotic, start at a low dose.
    • If choosing an Atypical Antipsychotic, start at a low or medium dose depending on the intensity of the psychotic symptoms.
    • Therapeutic effects of these medications usually take about a week to appear. As long as the individual is showing signs of improvement, the dose need not be increased.
    • But if in a given 1-week period the symptoms show no signs of improvement, the dose should then be increased. It is recommended to wait about 1 week after every dose increase to give a chance for improvements to take place before deciding to increase the dose further.
      • If with this approach the psychotic symptoms resolve completely, go to Step 4 while also following Step 1b.
      • If after 2 weeks at the maximum tolerated dose the psychotic symptoms do not resolve completely, consider the following options:
        • Taper and discontinue the current antipsychotic and repeat Step 1a.
        • Go to Step 2, with or without discontinuing the current antipsychotic.
  2.  
  3. Start an SSRI or a novel antidepressant (but avoid Bupropion, which could worsen the psychotic symptoms).
    • Therapeutic effects of these medications usually do not begin before 4 weeks of taking them on a daily basis, but a check-up with a physician should be offered after 1-2 weeks of starting the medication to check for any side-effects and to monitor the individual's condition.
    • If there are no signs of improvement in the depressive symptoms even after 6 weeks of treatment, including two weeks at an increased dose, or if the medication is not well tolerated due to side-effects, taper and discontinue the medication and at the same consider the following options:
      • repeat Step 1b with a different medication
      • implement Step 1a if not already done
      • go to Step 2
    • On the other hand, if after 4-6 weeks there are signs of improvement, then continue the treatment with regular check-ups.
      • As long as the depressive symptoms continue to improve, there is no need to increase the dose.
      • But if in a given 2-week period the symptoms show no further signs of improvement, the dose should then be increased. It is recommended to wait about 2 weeks after every dose increase to give a chance for improvements to take place before deciding to increase the dose further.
    • If with this approach the depressive symptoms resolve completely, go to Step 4.
    • On the other hand, if after 2 weeks at the maximum tolerated dose the condition has not resolved completely, go to Step 2.

Step 2: Try a course of ECT:

    • If the episode resolves, go to Step 4.
    • If after a full course the episode has not resolved, got to Step 3.

Step 3: Choose one of the following options (a or b):

  1. Add one of the following medications:
    • Start any of the above add-on medications at the lowest therapeutic dose. As long as the psychotic and depressive symptoms continue to improve with this intervention, there is no need to increase the dose.
      • Note that Clozapine must be titrated gradually and can take several weeks to reach a therapeutic dose.
    • But if in a given 2-week period the symptoms show no further signs of improvement, the dose should then be increased. It is recommended to wait about 2 weeks after every dose increase to give a chance for improvements to take place before deciding to increase the dose further.
      • If with this approach the psychotic and depressive symptoms resolve completely, go to Step 4.
      • If there are no signs of improvement even after 4 weeks of this step, including two weeks at an increased dose, or if the medication is not well tolerated due to side-effects, taper and discontinue the medication and at the same time repeat Step 3.
      • If after 2 weeks at the maximum tolerated dose the symptoms have improved but not resolved completely, repeat Step 3 with or without continuing the medication that was added-on.
  2.  
  3. Try a course of CBT.
    • If the episode resolves within 8 weeks, go to Step 4.
    • If the episode does not resolve or at least improve substantially within 8 weeks, continue with the CBT but repeat Step 3.

Step 4: Continue all useful medications for at least 2 years.  Antipsychotics can be stopped earlier if there are significant side effects. 

    • If CBT was used, follow-up booster sessions can be scheduled every month for 1 year.
    • If ECT was effective, then continue whatever medications were partially effective. Alternatively, monthly ECT treatments can also be used as maintenance treatment to prevent relapse.

 

For references in support of the above strategies, see: ref, ref, ref, ref, ref, ref.

 

Dysthymia

In Children and Adolescents