Management of Schizophrenia With Depressions

Samuel G. Siris, MD
Albert Einstein College of Medicine
Glen Oaks, NY, USA


Depression in schizophrenia is hard to diagnose and treat. A method for obtaining an accurate diagnosis of depression in schizophrenia was discussed. Strategies for treating depression in schizophrenic patients were presented.

Dr. Siris noted that depression in schizophrenia is associated with patient and family suffering and suicidal behavior. This is an important because approximately 10% of all schizophrenic lives end in suicide.

In order to diagnose depression in schizophrenic patients, the physician must first eliminate all other possible disorders. Many disorders mimic depression such as anemia, cancer, pulmonary disorders, autoimmune disorders and endocrine disorders. To establish the differential diagnosis of depression, the following factors should be taken into account: comorbid medical conditions; neuroleptic side effects such as akinesia, akathisia, dysphoric or anhedonic reactions; acute or chronic use and/or discontinuation of substances including "street" drugs, alcohol, nicotine and caffeine. Other factors to be considered are acute and chronic disappointment reactions; the "negative symptom" syndrome and demoralization syndrome. The clinician should realize that depression may be an intrinsic component of decompensation, either on a biological or psychological basis or may result from a psychotic episode. It is also possible that the patient may have an independent coexisting affective diathesis or schizoaffective disorder.

Once diagnosed, depression in schizophrenic patients may be treated in a number of ways. The first strategies to consider are to reduce or adjust neuroleptic dosage and change antipsychotic agents to "atypical" antipsychotics. Alternate strategies are the use of adjunctive agents such as antiparkinsonian agents or tricyclic-type antidepressants. Depending on the response obtained, non-tricyclic-type antidepressants such as selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), benzodiazepines, propranolol and electroconvulsive therapy may be used. Lithium and anticonvulsant agents can also be used. These medications may be used alone or in conjunction with psychosocial approaches.

Dr. Siris noted that his first therapeutic decisions are to either lower the dose of neuroleptics, change to an atypical antipsychotic agent or use an adjunctive tricyclic antidepressant such as imipramine. After 6 weeks on adjunctive imipramine, patients reported significant (P < 0.02) improvements in their clinical global impression (CGI) scores. Patients receiving a adjunctive placebo reported little to no change in their CGI scores.



Reporter: Andrea R. Gwosdow, PhD