Is the BPRS-5 subscale of the psychotic depression assessment scale a reliable screening tool for psychotic depression?: Results from the CRESCEND study

Prevalence and related factors of anxiety in first episode and drug naïve Chinese Han outpatients with psychotic major depression

BACKGROUND

Anxiety frequently occurs with major depressive disorder (MDD) but to a different extent in the various subtypes. Psychotic major depression (PMD) is a severe subtype of MDD that is under-identified and under-studied. We investigated the prevalence and related risk factors of anxiety in PMD patients.

METHODS

A total of 1718 first episode and drug naïve MDD patients were recruited. Measures included the Hamilton Depression Scale (HAMD), Clinical Global Impression-Severity scale (CGI-S), Hamilton Anxiety Scale (HAMA), and positive symptom scale of the Positive and Negative Syndrome Scale (PANSS), thyroid hormone levels, and metabolic parameters.

RESULTS

171 of the entire MDD study sample met the criteria for the PMD subtype. The prevalence of severe anxiety was much higher in PMD patients (22.8 %) than in non-PMD patients (0.4 %) (χ² = 294.69, P < 0.001, OR = 75.88, 95 % CI = 31.55-182.52). Compared to PMD patients without severe anxiety, PMD patients with severe anxiety had higher HAMD score, CGI-S score, positive symptom subscale score, suicide attempts, blood pressure, thyroid-stimulating hormone (TSH), anti-thyroglobulin (TgAb), and thyroid peroxidases antibody (TPOAb) levels. Furthermore, logistic regression analysis indicated that HAMD score and TSH levels were associated with severe anxiety in PMD patients.

LIMITATIONS

Our cross-sectional study cannot explain the causal relationship between anxiety severity and risk factors in PMD patients.

CONCLUSIONS

Our results suggest that PMD patients are more likely to experience severe anxiety than non-PMD patients. The severity of depression and TSH levels are independent risk factors for anxiety in PMD patients.

A Machine-Learning-Algorithm-Based Prediction Model for Psychotic Symptoms in Patients with Depressive Disorder

Psychotic symptoms are rarely concurrent with the clinical manifestations of depression. Additionally, whether psychotic major depression is a subtype of major depression or a clinical syndrome distinct from non-psychotic major depression remains controversial. Using data from the Research on Asian Psychotropic Prescription Patterns for Antidepressants, we developed a machine-learning-algorithm-based prediction model for concurrent psychotic symptoms in patients with depressive disorders. The advantages of machine learning algorithms include the easy identification of trends and patterns, handling of multi-dimensional and multi-faceted data, and wide application. Among 1171 patients with depressive disorders, those with psychotic symptoms were characterized by significantly higher rates of depressed mood, loss of interest and enjoyment, reduced energy and diminished activity, reduced self-esteem and self-confidence, ideas of guilt and unworthiness, psychomotor agitation or retardation, disturbed sleep, diminished appetite, and greater proportions of moderate and severe degrees of depression compared to patients without psychotic symptoms. The area under the curve was 0.823. The overall accuracy was 0.931 (95% confidence interval: 0.897–0.956). Severe depression (degree of depression) was the most important variable in the prediction model, followed by diminished appetite, subthreshold (degree of depression), ideas or acts of self-harm or suicide, outpatient status, age, psychomotor retardation or agitation, and others. In conclusion, the machine-learning-based model predicted concurrent psychotic symptoms in patients with major depression in connection with the “severity psychosis” hypothesis.

Cross-cultural evaluation of the French version of the Delusion Assessment Scale (DAS) and Psychotic Depression Assessment Scale (PDAS)

BACKGROUND

Major depressive disorder with psychotic features (MDDPsy), compared to nonpsychotic MDD, involves an increased risk of suicide and failure to achieve treatment response. Symptom scales can be useful to assess patients with MDDPsy. The aim of the present study was to validate French versions of the Delusion Assessment Scale (DAS) and Psychotic Depression Assessment Scale (PDAS).

METHODS

One hundred patients were included. The scales were filled out by psychiatrists. Data from participants who accepted a second interview were used for inter-judge reliability. The scalability and psychometric properties of both scales were assessed.

RESULTS

Data from 94 patients were used. Owing to low score variability between patients, the predefined threshold for scalability (≥0.40) was not reached for both scales. Factorial analysis of the DAS identified five factors, different from those of the original version. Five factors were also identified in the PDAS, of which two comprised items from the HDRS and the other three items from the BPRS. Floor and ceiling effects were observed in both scales, due in part to the construction of certain subscales. Unlike the PDAS, the DAS had good internal consistency. Multiple correlations were observed between the DAS dimensions but none between those of the PDAS. Both scales showed good inter-judge reliability. Convergent validity analyses showed correlations with HDRS, BPRS and CGI.

LIMITATIONS

Inter-judge reliability was calculated from a relatively small number of volunteers.

CONCLUSIONS

The good psychometric properties of the French versions of the DAS and PDAS could help in assessing MDDPsy, in particular its psychotic features, and hence improve response to treatment and prognosis.

Psychotic depression in hospitalized patients: Longitudinal outcomes of psychotic vs. nonpsychotic depression among inpatients

Even though psychotic depression is related to worse outcomes than nonpsychotic depression, there is increasing evidence that this greater severity is not solely explained by the depressive symptoms. We evaluated the socio-demographic and clinical characteristics, as well as the differences in clinical outcomes of psychiatric hospitalization between psychotic and non-psychotic depression. Two-hundred-eighty-eight depressive inpatients were assessed within 72 h after hospitalization and 24 h before discharge. We compared scores of Hamilton Depression Rating Scale 17-items (HDRS-17), Clinical Global Impression (CGI), Brief Psychiatric Rating Scale (BPRS), and Global Assessment of Functioning (GAF) between psychotic and nonpsychotic patients. Instruments were compared both cross-sectionally - on admission and discharge - and longitudinally. Longitudinal outcomes were corrected for potential confounders (sex, age, age at disease onset, years of study, previous history of mania/hypomania, electroconvulsive therapy in current hospitalization, history of attempted suicide, number of suicide attempts, and previous hospitalizations). One-hundred-thirty-one depressive inpatients (45.4%) presented psychotic features. Both groups showed similar HDRS-17 scores at admission and discharge. However, psychotic patients had worse scores on BPRS, CGI, and GAF at both timepoints. Both groups had similar improvement on HDRS-17 (P = 0.75), CGI (P = 0.5), and GAF (P = 0.84), but psychotic patients had greater improvement on BPRS (P < 0.001). Psychotic inpatients showed worse clinical and functional parameters. Nonetheless, the groups did not differ in depressive symptom severity. These findings reinforce the hypothesis that depressive episode with psychotic features is a more severe form of the disease irrespective of intensity of affective symptomatology.

Diagnostic Issues of Depressive Disorders from Kraepelinian Dualism to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Because the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) was mainly influenced by the neo-Kraepelinian approach, its categorical approach to defining mental disorders has been criticized from the viewpoint of etiological neutrality. In the context of bridging the gap between "presumed etiologies-based symptomatology" and "identifiable pathophysiological etiologies," the content in 5th edition, the DSM-5, has been revised to incorporate a combination of categorical and dimensional approaches. The most remarkable change of note regarding the diagnostic classification of depressive disorders in the DSM-5 is the splitting of mood disorders into bipolar disorders and depressive disorders, which is in accordance with the deconstruction of the Kraepelinian dualism for psychoses. The transdiagnostic specifiers "with mixed features," "with psychotic features," and "with anxious distress" are introduced to describe the relationships of depressive disorders with bipolar disorders, schizophrenia, and generalized anxiety disorder, respectively, in a dimensional manner. The lowering of the diagnostic threshold for major depressive disorder (MDD) may be caused by the addition of "hopelessness" to the subjective descriptors of depressive mood and the elimination of "bereavement exclusion" from the definition of MDD. Since the heterogeneity of MDD is equivalent to the Wittgensteinian "games" analogy, the different types of MDD are related not by a single essential feature but rather by "family resemblance." Network analyses of MDD symptoms may therefore need further review to elucidate the connections among interrelated symptoms and other clinical elements.

Clinical validation of the Psychotic Depression Assessment Scale (PDAS) against independent global severity ratings in older adults

OBJECTIVES

According to a recent study, ratings on the Psychotic Depression Assessment Scale (PDAS) obtained via a dedicated semi-structured interview are valid measures of the severity of psychotic depression. This study aimed to further test the validity, scalability and responsiveness of the PDAS in older adults using independent ratings on the Clinical Global Impression Scale - Severity (CGI-S) and the Montgomery-Asberg Depression Rating Scale (MADRS) as references.

METHODS

Ratings were performed at admission and discharge at two old age psychiatric wards in Flanders, Belgium. In total, 62 older adults (mean age: 74.3 years) with psychotic depression were included. The PDAS was rated by trained nurses using the semi-structured PDAS interview. Senior psychiatrists scored the participants on the CGI-S. Psychologists or experienced nurses rated participants on the MADRS. Clinical validity was assessed by correlating the PDAS total scores with CGI-S ratings and MADRS total scores. Mokken analysis was performed to assess the scalability of the PDAS. Responsiveness was assessed by comparing the proportion of participants in remission (PDAS total score <8 at study baseline and endpoint).

RESULTS

The Spearman correlation coefficients were 0.76 and 0.79 for the PDAS versus CGI-S and PDAS versus MADRS, respectively. The Mokken analysis yielded a Loevinger coefficient of 0.46, which is indicative of scalability. At admission, no participants met the PDAS remission criterion. At discharge, 54% (95% confidence interval: 47%-60%) of the patients met this criterion.

CONCLUSION

The PDAS appears to be a clinically valid, scalable and responsive measure of the severity of psychotic depression in older adults.

Psychotic major depression: challenges in clinical practice and research

Psychotic major depression is an under-researched and under-identified disorder. We highlight the major challenges both in clinical practice and in conducting research with people with this disorder. We also suggest which major issues need addressing to move treatment and knowledge of this disorder forward. Declaration of interest M.H. and A.H.Y. both report grants from the National Institute for Health Research (NIHR).

Clinical Validation of the Psychotic Depression Assessment Scale, Hamilton Depression Rating Scale-6, and Brief Psychiatric Rating Scale-5: Results from the Clinical Research Center for Depression Study

OBJECTIVE

The aim of this study was to validate the psychotic depression assessment scale (PDAS), which includes the six-item melancholia subscale from the Hamilton depression rating scale (HAMD-6) and the five-item psychosis subscale from the brief psychiatric rating scale (BPRS-5). Data from the Clinical Research Center for Depression (CRESCEND) study, which is a 52-week naturalistic trial, were analyzed.

METHODS

Fifty-two patients with psychotic depression from the CRESCEND study met our inclusion criteria. The patients underwent the following psychometric assessments: the PDAS, including HAMD-6 and BPRS-5, the clinical global impression scales, the HAMD, the positive symptom subscale, and the negative symptom subscale. Assessments were performed at the baseline and then at weeks 1, 2, 4, 8, 12, 24, and 52. Spearman correlation analyses were used to assess the clinical validity and responsiveness of the PDAS.

RESULTS

The clinical validity and responsiveness of the PDAS, including HAMD-6 and BPRS-5, were acceptable, with the exception of the clinical responsiveness of the PDAS for positive symptoms and the clinical responsiveness of BPRS-5 for negative symptoms.

CONCLUSION

The clinical relevance of the PDAS has been confirmed and this clinical validation will enhance its clinical utility and availability.

How many different symptom combinations fulfil the diagnostic criteria for major depressive disorder? Results from the CRESCEND study

BACKGROUND

The polythetic nature of major depressive disorder (MDD) in DSM- IV and DSM-5 inevitably leads to diagnostic heterogeneity.

AIMS

This study aimed to identify the number of depressive symptom combinations actually fulfilling the DSM-IV diagnostic criteria that can be found in Korean MDD patients and the relative frequencies of each combination.

METHODS

Using the data from the Clinical Research Center for Depression (CRESCEND) study in South Korea, we enrolled 853 MDD patients diagnosed using DSM-IV and scored as 8 or more on the Hamilton Depression Rating Scale (HAMD). Descriptive statistical analyses were performed to reveal the degree of diagnostic heterogeneity of the MDD.

RESULTS

This study identified 119 different depressive symptom combinations. The most common combination consisted of all nine depressive symptom profiles, and nine different combinations were each present in more than 3% of the patients.

CONCLUSION

The findings support the criticism that the diagnosis of MDD is not based on a single mental process, but on a set of 'family resemblances'.

Measuring negative symptoms in patients with schizophrenia: reliability and validity of the Korean version of the Motivation and Pleasure Scale-Self-Report

BACKGROUND

The Clinical Assessment Interview for Negative Symptoms (CAINS) is one of the validated interview measures of negative symptoms in psychotic disorders. The Motivation and Pleasure Scale-Self-Report (MPSR) is a self-report measure that assesses the motivation and pleasure domains of negative symptoms based on the CAINS. This study evaluated the reliability and validity of a Korean version of the MPSR.

METHODS

A total of 139 patients with schizophrenia completed the MPSR, CAINS, Scale for the Assessment of Negative Symptoms (SANS), Brief Psychiatric Rating Scales, Calgary Depression Scale for Schizophrenia, and other measures of trait and cognitive function.

RESULTS

The 15-item MPSR showed good internal consistency. In addition, it also had a good convergent validity with the Motivation and Pleasure subscale of the CAINS and the anhedonia/avolition subscale of the SANS. The scale was not associated with psychotic symptoms, agitation/mania, and depression/anxiety, and it showed good discriminant validity. MPSR scores were significantly correlated with Behavioral Activation System total score for trait measure.

CONCLUSION

The Korean version of the MPSR is a notable self-report method for examining the severity of negative symptoms in schizophrenia.

Clinical Significance of the Number of Depressive Symptoms in Major Depressive Disorder: Results from the CRESCEND Study

Our study aimed to establish the relationship between the number of depressive symptoms and the clinical characteristics of major depressive disorder (MDD). This would enable us to predict the clinical significance of the number of depressive symptoms in MDD patients. Using data from the Clinical Research Center for Depression (CRESCEND) study in Korea, 853 patients with DSM-IV MDD were recruited. The baseline and clinical characteristics of groups with different numbers of depressive symptoms were compared using the χ(2) test for discrete variables and covariance (ANCOVA) for continuous variables. In addition, the scores of these groups on the measurement tools were compared by ANCOVA after adjusting the potential effects of confounding variables. After adjusting the effects of monthly income and history of depression, a larger number of depressive symptoms indicated higher overall severity of depression (F [4, 756] = 21.458, P < 0.001) and higher levels of depressive symptoms (F [4, 767] = 19.145, P < 0.001), anxiety symptoms (F [4, 765] = 12.890, P < 0.001) and suicidal ideation (F [4, 653] = 6.970, P < 0.001). It also indicated lower levels of social function (F [4, 760] = 13.343, P < 0.001), and quality of life (F [4, 656] = 11.975, P < 0.001). However, there were no significant differences in alcohol consumption (F [4, 656] = 11.975, P < 0.001). The number of depressive symptoms can be used as an index of greater illness burden in clinical psychiatry.

Establishing the cut-off score for remission and severity-ranges on the Psychotic Depression Assessment Scale (PDAS)

BACKGROUND

The Psychotic Depression Assessment Scale (PDAS) is a rating scale dedicated to the measurement of severity in psychotic depression (PD). The aim of this study was to establish the PDAS cut-off for remission of PD as well as PDAS score-ranges for mild, moderate, and severe PD. The secondary aim was to test how remission, as defined by the PDAS, would perform as outcome measure when applied to the data from a large randomized controlled trial (RCT) in PD.

METHODS

The study was based on data from the Study of Pharmacotherapy in Psychotic Depression (STOP-PD). The cut-off for remission on the PDAS and the severity-ranges for mild, moderate, and severe PD were defined using the Clinical Global Impression - Severity scale (CGI-S) as reference by means of pair-wise receiver operating characteristic (ROC) analyses. Subsequently, it was tested whether remission on the PDAS could separate the effects of Olanzapine+Sertraline vs. Olanzapine+Placebo through an intention-to-treat, mixed-effects logistic regression of the data from STOP-PD.

RESULTS

According to the ROC analyses, the ideal cut-off for remission of PD was a PDAS total score <8, while the severity-ranges for mild, moderate and severe PD were 8-15, 16-23, and >23 respectively. When applying the PDAS total score <8 (remission) as outcome on the STOP-PD data, treatment with Olanzapine+Sertraline performed significantly better than Olanzapine+Placebo (p<0.001).

LIMITATIONS

The STOP-PD was not designed specifically to answer the research questions of the present study.

CONCLUSIONS

According to this study, a total score <8 on the PDAS corresponds to remission of PD.

Gender Differences in the Clinical Characteristics of Psychotic Depression: Results from the CRESCEND Study

OBJECTIVE

To test whether there are gender differences in the clinical characteristics of patients with psychotic depression (PD).

METHODS

Using data from the Clinical Research Center for Depression (CRESCEND) study in South Korea, we tested for potential gender differences in clinical characteristics among 53 patients with PD. The Psychotic Depression Assessment Scale (PDAS) and other psychometric scales were used to evaluate various clinical features of the study subjects. Independent t-tests were performed for normally distributed variables, Mann-Whitney U-tests for non-normally distributed variables, and χ(2)tests for discrete variables. In addition, to exclude the effects of confounding variables, we carried out an analysis of covariance (ANCOVA) for the normally distributed variables and binary logistic regression analyses for discrete variables, after adjusting the effects of marital status.

RESULTS

We identified more prevalent suicidal ideation (adjusted odds ratio [aOR]=10.316, p=0.036) and hallucinatory behavior (aOR=8.332, p=0.016), as well as more severe anxiety symptoms (degrees of freedom [df]=1, F=6.123, p=0.017), and poorer social and occupational functioning (df=1, F=6.265, p=0.016) in the male patients compared to the female patients.

CONCLUSION

Our findings suggest that in South Korean patients with PD, suicidal ideation, hallucinatory behavior, and anxiety is more pronounced among males than females. This should be taken into consideration in clinical practice.

Rating scales measuring the severity of psychotic depression

OBJECTIVE

Unipolar psychotic depression (PD) is a severe and debilitating syndrome, which requires intensive monitoring. The objective of this study was to provide an overview of the rating scales used to assess illness severity in PD.

METHOD

Selective review of publications reporting results on non-self-rated, symptom-based rating scales utilized to measure symptom severity in PD. The clinical and psychometric validity of the identified rating scales was reviewed.

RESULTS

A total of 14 rating scales meeting the predefined criteria were included in the review. These scales grouped into the following categories: (i) rating scales predominantly covering depressive symptoms, (ii) rating scales predominantly covering psychotic symptoms, (iii) rating scales covering delusions, and (iv) rating scales covering PD. For the vast majority of the scales, the clinical and psychometric validity had not been tested empirically. The only exception from this general tendency was the 11-item Psychotic Depression Assessment Scale (PDAS), which was developed specifically to assess the severity of PD.

CONCLUSION

In PD, the PDAS represents the only empirically derived rating scale for the measurement of overall severity of illness. The PDAS should be considered in future studies of PD and in clinical practice.