(December 13, 2007 - Insidermedicine) Welcome to Insidermedicine's If I Had, where we get a chance to ask an expert what they would do if they had a medical condition.
Today, I have the pleasure of introducing Dr. James Potash, an Associate Professor in the Department of Psychiatry and Behavioral Sciences, and Director of Mood Disorders Research at Johns Hopkins University. Dr. Potash's research focusses on the psychotic forms of depression and bipolar disorder, and the hypothesis that genes predisposing to these forms of illness may also predispose to schizophrenia.
We asked Dr. Potash for his thoughts on the treatment of psychotic depression.
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Dr. Potash: So, if I had a family member with psychotic depression, I would take her to a psychiatrist as quickly as possible. Psychotic depression is really the most severe form of depression, whereas depression in general is very common and takes many forms, the psychotic subset is a pretty smallish subset – it’s about 6% of all people who have what we call major depression or clinical depression. And the psychotic part means that they have hallucinations, meaning they’re hearing voices, or delusions – they’re convinced of things that aren’t true, like thinking they have cancer when there’s no evidence that they do, for example. Thinking they’re dying, thinking they’re being punished by the devil for having done something horrible that they didn’t actually do. When people have psychotic depression they’re really not thinking clearly at all, and so they certainly need immediate attention from a psychiatrist.
What is the key to assessing psychotic depression?
Dr. Potash: One thing that’s important for people to understand is that the key in assessing psychotic depression, as in assessing any form of mood disorder, the key is a very careful interview of the patient himself or herself. And in addition, the other critical key is getting as much information as possible from the people who know the patient well, which is a husband, a wife, parents, whoever knows the patient well. We do not have any physical tests that can help clarify the situation. That being said, there are physical tests that can give you some information that’s sometimes useful. So, for example, testing people’s urine to see whether they’re using illegal drugs, which is not that uncommon in depression. Testing liver function enzymes can tell you about whether they’ve been drinking alcohol, which again is not so uncommon. Looking at thyroid hormone tests sometimes can be useful because, occasionally, abnormalities there can lead to depression.
Are there any other types of treatments?
Dr. Potash: Other things that occasionally can be helpful are, for example, something called an EEG, electroencephalogram. Now that’s for a situation where it might be hard to distinguish psychotic depression from delirium. So, delirium is a transient state of confusion that is a fairly common side effect of a variety of medications, and also can be brought on by a variety of medical illnesses. So, occasionally, there can be uncertainty there, and an EEG can sometimes tell you it’s delirium, rather than psychotic depression.
What happens with most cases of psychotic depression?
Dr. Potash: When a person has psychotic depression, often, probably usually, the person ought to be admitted into an inpatient psychiatric unit or psychiatric hospital, because, typically, in that state of mind, people are not thinking clearly enough to be able to stick with an outpatient program. Sometimes people, when they get admitted, are given ECT, electroconvulsive treatment, or shock treatment. Shock treatment is certainly something that has gotten a bad name in some circles. There are a lot of misunderstandings about it – it is the single most effective treatment we have for depression. It’s helpful 75-80% of the time. It’s been around for 69 years or so now, so it’s been around a long time, it’s been very well studied. It works. Side effects are minimal. The one substantial side effect we worry about is memory impairment, and that’s typically short-lived when it happens. So ECT is an excellent treatment. The other, most common treatment is the combination of an antidepressant medication and an antipsychotic, or a neuroleptic medication.
If I had a family member with psychotic depression…
Dr. Potash: So if I had a family member with psychotic depression, I would want her to get seen by a psychiatrist as quickly as possible because of the dangerousness of that state, and I would expect that there would be a good chance that the psychiatrist would decide the patient needed to be admitted into the hospital. And I would want to be very open to the possibility that ECT would be the treatment recommended. I would also expect that an antipsychotic or antidepressant medication might be recommended, instead of ECT. And, I would expect that those treatments ought to get the patient, ought to get my family member, well again before long.