Major Depressive Disorder (MDD) With Psychotic Features

what's up everybody dr rossi here at strengths and sneakers i'm a board-certified psychiatrist making mental health content here on youtube and various other platforms if you're new to the channel i'm going to ask you to go ahead and subscribe to the channel it helps me to know this material is helpful to you and it's providing value in your life and if you're returning i appreciate the love and support as always so today's topic is going to be major depressive disorder with psychotic features now this is a diagnosis that i often receive questions about and it can be really confusing right because how do we know if the person has schizophrenia how do we know if they have schizoaffective disorder or what about bipolar disorder with psychotic features all of these things can be very confusing so they all have psychotic symptoms such as delusions and hallucinations as common core features so in this video what i'm going to do is explain to you how we navigate this diagnostic dilemma let's start with some of the basics right i want to take you guys back through the diagnostic criteria for major depressive disorder because for one to be diagnosed with mdd with psychotic features they must meet criteria for major depressive disorder as defined by the dsm-5 tr now as a reminder to meet the criteria the person must have five okay so five of nine symptoms within a two week period and at least one of those symptoms must be either depressed mood or loss of interest in medical school they teach you a really clever mnemonic called sig e caps and an interesting fact about this mnemonic is that it's written the way you would fill out a paper prescription for depression treatment so sig energy capsules is what it stands for and this is what you would give a patient or a person with major depression because of the low energy and loss of interest commonly seen in these depressive episodes so it's sig energy capsules and the sigi caps each one of those is one of the nine criteria to diagnose major depressive disorder now i promised you guys i would talk about the other criteria as i said you must have either depressed mood or loss of interest but the other criteria that you can have to complete the five out of nine symptoms required to make the diagnosis will include things such as weight loss or weight gain so basically some type of change in your weight as a result of the depressed mood insomnia or hypersomia so either not sleeping at all not being able to fall asleep at night or sleeping too much what we call psychomotor agitation or retardation in my experience psychomotor retardation is more telling of a depressive episode you could have fatigue or loss of energy you could have feelings of worthlessness or guilt you could have poor concentration or focus as well as recurrent thoughts of death or suicidal ideation so what we have here at this point is we have a person who meets the dsm-5 criteria for major depressive disorder they have five out of the nine symptoms over that two week period now what if along with this major depressive episode the person also has some loss of reality based thinking in conjunction with their major depressive episode so not only do they have depression but they also have loss of reality based thinking now what does that include that will include things like delusions and hallucinations with the delusions being slightly more common but hallucinations are also common in depression with psychotic features now the delusions can range from persecutory to paranoid and other types can occur as well but those are more of the common ones that we see now with the persecutory delusion these are ones where the person feels attacked or victimized by others they may even believe that people are coming into their home to harm them they and they'll usually point to things like uh things being misplaced in the home or something's out of order something that they put somewhere wasn't in the place they left it last and they'll point to this as evidence to support this delusional thinking that somebody is coming into their home and trying to harm them a common paranoid delusion is one where the person believes they are being followed they believe they're being watched in some way and they'll usually present evidence of a car that's commonly parked outside of their home or a car that they see on the way to work every day or a person they keep seeing on the street or something like that and they simply cannot believe that this may be a coincidence or it just may be someone who travels to work the same route every day in the same way that they do but they're unable to really appreciate that fact now the reason behind that is because a delusion is defined as a fixed false belief so although there may be rational explanations for the things that are going on around this person the pre the patient's reality is not the same why their reality is this delusional thinking this is real to them it feels real to them it's distressing to them and you also as the clinician have to understand that this is very real to them even though you might see other ways of explaining it and you have to be very very careful when you challenge somebody's delusions you don't want to just come out and say to the patient hey you know what it doesn't make sense what you're saying it's likely that that person you keep seeing every day just works in the same office building as you right like if you do that and you present that information they're not going to buy it anyway it may be perfectly reasonable explanation it may even be true but it doesn't matter these are fixed false beliefs so one of the most important points i want to present to you guys here is that these psychotic symptoms these delusions hallucinations this disorganized thinking that's going on it's only happening in the presence of a major depressive episode that's very important that is your key point so in order to be diagnosed with depression with psychotic features these psychotic features only occur when the person is in the midst of a depressive episode they don't occur outside of the depressive episode so for example if you treat the depression effectively the psychotic symptoms resolve if the psychotic symptoms remain after the depressive episode is successfully treated then you need to re-evaluate your diagnosis so that's one of the main ways that we separate major depressive disorder with psychotic features from schizophrenia is that these these psychotic symptoms are occurring only within the context of the depressive episode now you might be saying well what about bipolar disorder with psychotic features now this can present the same way the psychotic features will happen during an episode of mania so the person will be in the manic phase of bipolar illness and often the delusions will have a grandiose nature to them they'll be grandiose theme associated with them for example the patient may believe that they are a prominent religious figure they may believe that the government is plotting against them and they're the only ones who can uncover the story and unravel this complicated plot against everyone in the united states they're going to be the one to save the world or whatever the case is so there's a grandiose nature to it again similar concept but likely to occur during mania or during the manic phase of illness and likely to have a grandiose theme associated with them that's not always the case other things obviously can happen too but that is the more common scenario the delusions associated with the depressive episodes also tend to be somewhat reasonable uh if you're if you believe that somebody is watching you or following you it's possible that they are right we don't know maybe they are in things like schizophrenia the delusions are usually bizarre in nature although they can also be plausible so it becomes very nuanced but in general that's what we would be thinking about here the final point i want to make about the delusions associated with depressive episodes is that they tend to be what we call mood congruent so when i say mood congruent what i mean here is that they're consistent with how the patient is feeling the person's feeling depressed so they're having persecutory delusions so it's not a far stretch for a person who is severely depressed to feel like people want to harm them for no good reason right this would not be that far of a stretch to make and it's and you can see how it can be mood congruent for the patient going through a depressive episode and the treatment for major depressive disorder with psychotic features is actually well established and it generally consists of two forms of treatment the first one is medication treatment in a medication based treatment you're going to combine a medication such as an sri so a serotonin reuptake inhibitor or other antidepressant medication with a dopamine blocking medication to treat the psychotic features now the dopamine blocking medications could be any examples here it could be aripiprazole it could be risperidol there's many different options there and you're going to make that selection largely based off of the side effect profile and what the patient can tolerate because these medications do have a much more difficult side effect profile to tolerate so we have to be careful which ones we select the other option outside of medication management is to undergo an index phase of electroconvulsive therapy or ect and this is usually for the person who is severely depressed who's not eating not attending to adls and is in danger of harming themselves in some way now patients should remain on medication for at least six months there's some debate about this but in the research that i've done six months seems to be the right amount of time to remain on both the antidepressant and the dopamine blocking medication and this is very important because there was a recent paper that came out that showed that relapse is likely to occur if you are to stop the dopamine blocking medication specifically earlier than six months so my recommendation to my patients is always to remain on the medication for six months and then consider tapering off of the dopamine blocking medication at that point to see how the person does as far as the antidepressant medications go those should be continued for at least a year and then at the point where the person has been in remission for 12 months and has been asymptomatic you can start tapering that medication off and see if symptoms recur if they don't great you can come off the medication fully if symptoms develop again then you can taper down to what we call the lowest effective dose and remain on it for a longer period of time and reassess clinically several months later so the difference here being six month period of time that you should be on the dopamine blocking medication and about a one year period of time to stay on the antidepressant at which point when six months is over you can start to taper the dopamine blocking medication and at the one year mark you could begin to taper the antidepressant and see if symptoms recur if not great then the person could come off the medication fully if somebody chooses to do the index phase of vct it consists of a total of 12 sessions which are usually completed over a one month period and you would normally be doing the sessions three times per week usually every monday wednesday and friday if somebody is having difficulty with the treatments and tolerating them they can be done twice a week say tuesdays and thursdays with more time in between treatments with that said i'm going to go ahead and hold the video here i'd love to take your questions and comments below and if you haven't done so already please subscribe to the channel it really helps me to keep making this content for you

Channel: Shrinks In Sneakers

Views: 16,557

Keywords: Psychiatry, Major Depression, Depression, Psychotic depression

Id: knza7U4kmmA

Length: 12min 7sec (727 seconds)

Published: Mon May 02 2022