International Journal of Psychiatry in Clinical Practice
ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20
Mirtazapine effectiveness in a patient with refractory psychotic depression Marcelo Feijo De Mello To cite this article: Marcelo Feijo De Mello (1999) Mirtazapine effectiveness in a patient with refractory psychotic depression, International Journal of Psychiatry in Clinical Practice, 3:2, 141-142 To link to this article: http://dx.doi.org/10.3109/13651509909024776
Published online: 12 Jul 2009.
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Article views: 13
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Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijpc20 Download by: [University of California, San Diego]
Date: 11 November 2015, At: 08:15
C 1999 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 1999 Volume 3 Pages 141 - 142
141
Mirtazapine effectiveness in a patient with refractory psychotic depression MARCEL0 FEIJO DE MELLO
Downloaded by [University of California, San Diego] at 08:15 11 November 2015
Department of Psychiatry, Hospital do Servidor Piblico Estadual, Siio Paulo, Brazil
Correspondence Address Dr M Feijo de Mello, MD, PhD, Department of Psychiatry, ‘Hospital do Servidor Piblico Estadual’, Urussui st., 71 conj., 133 Siio Paulo-SP Brazil, 04542-050 Phonelfaw (01 1) 8205907/ E-mail: [email protected]
The author describes a patient with recurrent depression, according to DSM-IV diagnostic criteria. The features were of a delusional depressive episode lasting 5 years, associated with severe impairment of psychosocial functioning. The patient also had chronic hepatitis, of unknown aetiology, and portal hypertension with some high gastrointestinal bleeding episodes. The depressive episode had been treated unsuccessfully with therapeutic doses of imipramine and lithium augmentation associated with haloperidol and, afterwards, with risperidone. Mirtazapine was introduced, coadministered with haloperidol and after 8 weeks there was an improvement in delusional depressive and other negative symptoms. The patient remained well for 9 months. This case indicates that mirtazapine is an option for patients with psychotic depression who are refractive to tricyclic antidepressants. Mirtazapine is also a safe drug, well tolerated in this severe clinical condition. (Int J Psych Clin Pract 1999; 3: 141- 142) Keywords
Received 19 October 1998; accepted for publication 4 February 1999
psychotic depression therapeutics
INTRODUCTION
P
revious studies have shown that 14-25% of patients with major depression have psychotic symptoms. 1.2 They represent 14% of psychiatric inpatie n t ~and , ~ 15-54% of all psychotic patient^.^ Despite this high prevalence, psychotic depression (PD) receives little attention. Typically, PD has a worse outcome with a greater number of relapses and recurrences, even in those receiving ~reatment.~ Comparing outcomes in PD and schizophrenia, Coryell et a16 found similarities in psychological functioning. A retrospective study found more similarities in variables like age, sex, age of onset of illness and psychosocial functioning between the schizophrenic patients and the psychotically depressed patients than between the schizophrenic patients and depressed patients without psychotic symptoms.’ Compared to major depression without psychotic symptoms, PD responds less well to antidepressants.’ The addition of an antipsychotic drug seems to be more effective than using an antidepressant alone.’- l 1 The SSRIs have not been extensively studied in psychotic depression. Amoxapine (with dopaminergic properties) may produce a more favourable response.“- l8 Banov and colleagues’’ studied all cases treated with clozapine over 16 years. They found a favourable response in 46%of unipolar patients, and a 44% response in bipolar
antidepressants tolerability
depression; low response rates compared to 67% in schizophrenic patients. ECT is still the most effective treatment for the symptomatic remission of PD, but the value of maintenance treatment is uncertain, as relapse and recurrence are the rule.
CASE REPORT A 58-year-old woman, with a 28-year history of recurrent depressive disorder according to DSM-IV diagnostic criteria,” presented to our outpatient service. The features were of a delusional depressive episode lasting 5 years. Depressive, nihilistic and guilty delusions were present, associated with low mood and severe impairment of psychosocial functioning. The patient had many previous depressive episodes, each lasting some months. Treatment with haloperidol and ECT led to a partial remission. The patient also had chronic hepatitis, of unknown aetiology, with portal hypertension and gastrointestinal bleeding. The most recent episode of depression had initially been treated with imipramine at doses up to 300 mg/day (serum levels of 179 pg/ml) augmented with lithium (600 mg/ day), together with 10 mg/day of haloperidol; however, the clinical picture worsened. Imipramine cessation led to an improvement in delusions. Risperisone 6 mg/day for 3
Downloaded by [University of California, San Diego] at 08:15 11 November 2015
142
M Feijo de Mello
months had been prescribed, but the depressive symptoms worsened. At the time of presentation, she was found to have leukopenia (< 1500 wbdmm’), leading to discontinuation of all prescriptions. At the same time the patient had an epileptic fit, probably due to hepatic failure. After 10 days of hospitalization, the clinical picture had stabilized. Mirtazapine 60 mg/day and haloperidol 10 mg/ day were introduced, with total remission of delusions and depressive symptoms after 8 weeks. Some avolitional symptoms were still present, but she showed an unexpected interest in housework and the care of her grandson. She remained stable for 9 months, when she showed some depressive symptoms, which remitted when the mirtazapine dose was increased to 75 muday. The history of this patient indicates that mirtazapine may be a choice for patients with psychotic depression which is refractory to tricyclic antidepressants. Mirtazapine is also a safe and well-tolerated drug in this condition.
KEY POINTS 0 0
0 0
0
One third of depressive patients are nonresponders to a first antidepressive treatment Augmentation strategies with lithium and neuroleptics are usual but led to an adverse effect accentuation Depression with psychotic features is particularly resistant, and recurrence more frequent Mirtazapine has a unique mechanism of action that allows a potent antidepressant action with reduced adverse effects The alfa2 pre-synaptic antagonism promoted by mirtazapine is a promissory focus of research in psychotic depression
REFERENCES 1. Johnson J, Horwath E, Weissman MM (1991) The validity of major depression with psychotic features based on a community study. Arch Gen Psychiatry 4 8 1075-81. 2. Rothschild AS, Schatzberg AF (1994) Diagnosis and treatment of psychotic (delusional) depression. In: Severe depressive disorders (ed. L Grunhaus and JF Greden) Progress in psychiatry 44, 195-207. 3. Coryell W, Pfohl B, Zimmerman M (1984) The clinical and neuroendocrine features of psychotic depression. J Nerv Ment Dis 172: 521-8. 4. Dubovski SL, Thomas M (1991) Psychotic depression: advance in conceptualisation and treatment. Hospital and Community Psychiatry 43 (12): 1189-98. 5 . Petrides G, Dhossche D, Fink M, Francis A (1994) Continuation ECT: relapse prevention in affective disorders. Convulsive Ther 10 189-94. 6. Coryell W, Lavori P, Endicott J et a1 (1984) Outcome in schizoaffective psychotic and nonpsychotic depression. Arch Gen Psychiatry 41: 787-91. 7. Mello MF, Cereser MG, Baggio VM,Elkis E (1997) Depression as a separate entity. Paper presented at American Psychiatric Association Congress, San Diego, CA, 1997. APA, Washington DC. 8. Chan CH, Janicak PG, Davis JM et a1 (1987) Response of psychotic and non-psychotic depression to tricyclic antidepressants. J Clin Psychiatry 48: 197-200. 9. Charney DS, Nelson JC (1981) Delusional and non-delusional unipolar depression: further evidence for distinct subtypes. Am J Psychiatry 138: 328-33.
10. Frances A, Brown RF’, Kocsis J et a1 (1981) Psychotic depression: a separate entity? Am J Psychiatry 138: 831-3. 11. Mirtes RE, Mandel MR (1979) The treatment of psychotic major depressive disorder with drugs and electroconvulsive therapy.J New Ment Dis 167: 726-33. 12. Coupet J, Rauch CE, Sznes-Myers VA et a1 (1979) Amoxapine: an antidepressant with antipsychotic properties. Biochem Pharmacol 28: 2514- 5. 13. Cohen BM, Hams PQ, Altesman RI et a1 (1982) Amoxapine neuroleptic as well as antidepressants? Am J Psychiatry 139: 1165-67. 14. Fulton A, Norman T, Burrows GD (1982) Ligand binding and platelet uptake studies of lozapine, amozapine and their 8 hydroxilated derivatives.J Affect Dis 4 113-9. 15. Anton RF, Sexauer JD, Randall CF (1983) Amoxapine elevates serum prolactin in depressed men. J Affect Dis 5: 305 - 10. 16. Anton RF, Sexauer JD (1983) Efficacy of amoxapine in psychotic depression. Am J Psychiatry 140: 1344- 7. 17. Anton RF, Ressner EL, Hitri A et a1 (1985) Efficacy of amoxapine in psychotic depression: relationship to serum prolcatin and neuroleptic activity.J Clin Psychiatry (Monograph series) 3(1): 8-13. 18. Burch EA, Anton RF, Carson WH (1994) Mood congruent and incongruent psychotic depressives, are they the same? J Affect Dis 31 (4): 275-80. 19. Banov MD, Zarate CA, Jr, Tohen M et a1 (1994) Clozapine therapy in the refractory affective disorders: polarity predicts response in a long-term follow-up. J Clin Psychiatry 55: 295300.
ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20
Mirtazapine effectiveness in a patient with refractory psychotic depression Marcelo Feijo De Mello To cite this article: Marcelo Feijo De Mello (1999) Mirtazapine effectiveness in a patient with refractory psychotic depression, International Journal of Psychiatry in Clinical Practice, 3:2, 141-142 To link to this article: http://dx.doi.org/10.3109/13651509909024776
Published online: 12 Jul 2009.
Submit your article to this journal
Article views: 13
View related articles
Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijpc20 Download by: [University of California, San Diego]
Date: 11 November 2015, At: 08:15
C 1999 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 1999 Volume 3 Pages 141 - 142
141
Mirtazapine effectiveness in a patient with refractory psychotic depression MARCEL0 FEIJO DE MELLO
Downloaded by [University of California, San Diego] at 08:15 11 November 2015
Department of Psychiatry, Hospital do Servidor Piblico Estadual, Siio Paulo, Brazil
Correspondence Address Dr M Feijo de Mello, MD, PhD, Department of Psychiatry, ‘Hospital do Servidor Piblico Estadual’, Urussui st., 71 conj., 133 Siio Paulo-SP Brazil, 04542-050 Phonelfaw (01 1) 8205907/ E-mail: [email protected]
The author describes a patient with recurrent depression, according to DSM-IV diagnostic criteria. The features were of a delusional depressive episode lasting 5 years, associated with severe impairment of psychosocial functioning. The patient also had chronic hepatitis, of unknown aetiology, and portal hypertension with some high gastrointestinal bleeding episodes. The depressive episode had been treated unsuccessfully with therapeutic doses of imipramine and lithium augmentation associated with haloperidol and, afterwards, with risperidone. Mirtazapine was introduced, coadministered with haloperidol and after 8 weeks there was an improvement in delusional depressive and other negative symptoms. The patient remained well for 9 months. This case indicates that mirtazapine is an option for patients with psychotic depression who are refractive to tricyclic antidepressants. Mirtazapine is also a safe drug, well tolerated in this severe clinical condition. (Int J Psych Clin Pract 1999; 3: 141- 142) Keywords
Received 19 October 1998; accepted for publication 4 February 1999
psychotic depression therapeutics
INTRODUCTION
P
revious studies have shown that 14-25% of patients with major depression have psychotic symptoms. 1.2 They represent 14% of psychiatric inpatie n t ~and , ~ 15-54% of all psychotic patient^.^ Despite this high prevalence, psychotic depression (PD) receives little attention. Typically, PD has a worse outcome with a greater number of relapses and recurrences, even in those receiving ~reatment.~ Comparing outcomes in PD and schizophrenia, Coryell et a16 found similarities in psychological functioning. A retrospective study found more similarities in variables like age, sex, age of onset of illness and psychosocial functioning between the schizophrenic patients and the psychotically depressed patients than between the schizophrenic patients and depressed patients without psychotic symptoms.’ Compared to major depression without psychotic symptoms, PD responds less well to antidepressants.’ The addition of an antipsychotic drug seems to be more effective than using an antidepressant alone.’- l 1 The SSRIs have not been extensively studied in psychotic depression. Amoxapine (with dopaminergic properties) may produce a more favourable response.“- l8 Banov and colleagues’’ studied all cases treated with clozapine over 16 years. They found a favourable response in 46%of unipolar patients, and a 44% response in bipolar
antidepressants tolerability
depression; low response rates compared to 67% in schizophrenic patients. ECT is still the most effective treatment for the symptomatic remission of PD, but the value of maintenance treatment is uncertain, as relapse and recurrence are the rule.
CASE REPORT A 58-year-old woman, with a 28-year history of recurrent depressive disorder according to DSM-IV diagnostic criteria,” presented to our outpatient service. The features were of a delusional depressive episode lasting 5 years. Depressive, nihilistic and guilty delusions were present, associated with low mood and severe impairment of psychosocial functioning. The patient had many previous depressive episodes, each lasting some months. Treatment with haloperidol and ECT led to a partial remission. The patient also had chronic hepatitis, of unknown aetiology, with portal hypertension and gastrointestinal bleeding. The most recent episode of depression had initially been treated with imipramine at doses up to 300 mg/day (serum levels of 179 pg/ml) augmented with lithium (600 mg/ day), together with 10 mg/day of haloperidol; however, the clinical picture worsened. Imipramine cessation led to an improvement in delusions. Risperisone 6 mg/day for 3
Downloaded by [University of California, San Diego] at 08:15 11 November 2015
142
M Feijo de Mello
months had been prescribed, but the depressive symptoms worsened. At the time of presentation, she was found to have leukopenia (< 1500 wbdmm’), leading to discontinuation of all prescriptions. At the same time the patient had an epileptic fit, probably due to hepatic failure. After 10 days of hospitalization, the clinical picture had stabilized. Mirtazapine 60 mg/day and haloperidol 10 mg/ day were introduced, with total remission of delusions and depressive symptoms after 8 weeks. Some avolitional symptoms were still present, but she showed an unexpected interest in housework and the care of her grandson. She remained stable for 9 months, when she showed some depressive symptoms, which remitted when the mirtazapine dose was increased to 75 muday. The history of this patient indicates that mirtazapine may be a choice for patients with psychotic depression which is refractory to tricyclic antidepressants. Mirtazapine is also a safe and well-tolerated drug in this condition.
KEY POINTS 0 0
0 0
0
One third of depressive patients are nonresponders to a first antidepressive treatment Augmentation strategies with lithium and neuroleptics are usual but led to an adverse effect accentuation Depression with psychotic features is particularly resistant, and recurrence more frequent Mirtazapine has a unique mechanism of action that allows a potent antidepressant action with reduced adverse effects The alfa2 pre-synaptic antagonism promoted by mirtazapine is a promissory focus of research in psychotic depression
REFERENCES 1. Johnson J, Horwath E, Weissman MM (1991) The validity of major depression with psychotic features based on a community study. Arch Gen Psychiatry 4 8 1075-81. 2. Rothschild AS, Schatzberg AF (1994) Diagnosis and treatment of psychotic (delusional) depression. In: Severe depressive disorders (ed. L Grunhaus and JF Greden) Progress in psychiatry 44, 195-207. 3. Coryell W, Pfohl B, Zimmerman M (1984) The clinical and neuroendocrine features of psychotic depression. J Nerv Ment Dis 172: 521-8. 4. Dubovski SL, Thomas M (1991) Psychotic depression: advance in conceptualisation and treatment. Hospital and Community Psychiatry 43 (12): 1189-98. 5 . Petrides G, Dhossche D, Fink M, Francis A (1994) Continuation ECT: relapse prevention in affective disorders. Convulsive Ther 10 189-94. 6. Coryell W, Lavori P, Endicott J et a1 (1984) Outcome in schizoaffective psychotic and nonpsychotic depression. Arch Gen Psychiatry 41: 787-91. 7. Mello MF, Cereser MG, Baggio VM,Elkis E (1997) Depression as a separate entity. Paper presented at American Psychiatric Association Congress, San Diego, CA, 1997. APA, Washington DC. 8. Chan CH, Janicak PG, Davis JM et a1 (1987) Response of psychotic and non-psychotic depression to tricyclic antidepressants. J Clin Psychiatry 48: 197-200. 9. Charney DS, Nelson JC (1981) Delusional and non-delusional unipolar depression: further evidence for distinct subtypes. Am J Psychiatry 138: 328-33.
10. Frances A, Brown RF’, Kocsis J et a1 (1981) Psychotic depression: a separate entity? Am J Psychiatry 138: 831-3. 11. Mirtes RE, Mandel MR (1979) The treatment of psychotic major depressive disorder with drugs and electroconvulsive therapy.J New Ment Dis 167: 726-33. 12. Coupet J, Rauch CE, Sznes-Myers VA et a1 (1979) Amoxapine: an antidepressant with antipsychotic properties. Biochem Pharmacol 28: 2514- 5. 13. Cohen BM, Hams PQ, Altesman RI et a1 (1982) Amoxapine neuroleptic as well as antidepressants? Am J Psychiatry 139: 1165-67. 14. Fulton A, Norman T, Burrows GD (1982) Ligand binding and platelet uptake studies of lozapine, amozapine and their 8 hydroxilated derivatives.J Affect Dis 4 113-9. 15. Anton RF, Sexauer JD, Randall CF (1983) Amoxapine elevates serum prolactin in depressed men. J Affect Dis 5: 305 - 10. 16. Anton RF, Sexauer JD (1983) Efficacy of amoxapine in psychotic depression. Am J Psychiatry 140: 1344- 7. 17. Anton RF, Ressner EL, Hitri A et a1 (1985) Efficacy of amoxapine in psychotic depression: relationship to serum prolcatin and neuroleptic activity.J Clin Psychiatry (Monograph series) 3(1): 8-13. 18. Burch EA, Anton RF, Carson WH (1994) Mood congruent and incongruent psychotic depressives, are they the same? J Affect Dis 31 (4): 275-80. 19. Banov MD, Zarate CA, Jr, Tohen M et a1 (1994) Clozapine therapy in the refractory affective disorders: polarity predicts response in a long-term follow-up. J Clin Psychiatry 55: 295300.
