Psychotic (Delusional) Major Depression in the Elderly: A Review

Abstract

The prevalence in the community of psychotic (delusional) major depression (PMD) in the elderly was found to be 1%. In inpatient settings the frequency of the disorder varies between 24% and 53%. There is also evidence that its frequency increases in old age. In the elderly, PMD compared to non-PMD was found to be a more severe and melancholic form of depression with more psychomotor disturbances (agitation or retardation) and feelings of guilt, more anxiety and hypochondriacal complains and less insight. Delusional beliefs of paranoid and hypochondriacal content have been found to be prominent. Additionally, elderly psychotic depressives (PDs) are possibly at greater risk of suicide attempt. Also, elderly PDs have been observed to have more cognitive processing difficulties. As regards neurobiological findings, they have been found to have lower dopamine-beta-hydroxylase activity, smaller volume of prefrontal cortex, more brain stem and left-side frontotemporal atrophy, enlargement of the third ventricle and pontine reticular formation hypertensities. The prognosis for the disorder seems worse, with higher relapse rates and mortality although not all studies are in agreement. In the acute phase, the response to ECT is favourable (88%), however the response rates to combination of an antipsychotic and an antidepressant (25-50%) seem to be inferior to those observed in younger adults (70-80%). Close follow-up and continuation therapy with an antidepressant is needed to avoid relapses.

Características clínicas del trastorno depresivo mayor en tratamiento en el nivel secundario de atención

“…La prevalencia de depresión psicótica es variable: 15 a 20% en población general 24 y 24 a 53% en hospitalizados 25 ; por tanto, nuestras cifras (32,1%) son aceptables por tratarse de episodios graves y atención especializada. Pero estos síntomas psicóticos también podrían constituir señales de una posible depresión bipolar.…”

Challenges in the Treatment of Major Depressive Disorder With Psychotic Features

“…Studies have found that the frequency of psychotic depression in people over age 60 in inpatient settings varies between 24% and 53%. 17 …”

Considerations on the ICD-11 Classification of Psychotic Depression

“…PD is classified as a subtype of severe unipolar depression/severe depression in bipolar disorder in the two current major diagnostic systems, namely the 10th revision of the International Classification of Disease (ICD-10) [1] and the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [2]. PD is prevalent [3,4], underdiagnosed [5], undertreated [6] and has a high morbidity and mortality [7,8,9], but has received disproportionally little attention compared with other less prevalent and less severe mental disorders [10]. …”

“…F20.0 for paranoid schizophrenia) and that the majority of these were used very rarely. The number of diagnostic syndromes should obviously be kept to a reasonable minimum, but since PD is a rather prevalent disorder [3,4,10] and already defined in the diagnostic manuals, this argument seems misplaced in the discussion of defining PD as a distinct diagnostic syndrome.…”

“…A very recent study has caused reason to question the validity of PD due to its finding of low diagnostic stability over 10 years [57]. However, this study is affected by several limitations (a very young sample, a large proportion of males and changing diagnostic instruments over time) and the findings are in contrast to a number of studies reporting high diagnostic stability of PD [3,56,58]. Furthermore, changes in diagnoses over time and so-called diagnostic drift exists for all mental disorders [59,60] and for virtually all diseases in general [61,62].…”