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Major depression with psychotic features (MD-Psy), a disorder with considerable morbidity and mortality,1,2 is more common than is generally realized and is encountered frequently in clinical practice. Although studies conducted in both inpatient and outpatient settings have estimated that 16% to 54% of adults with depression are also psychotic,3-8 MD-Psy often is not diagnosed accurately because the psychosis may be subtle, intermittent, or concealed - leading to a misdiagnosis of nonpsychotic depression.9
A study of consecutively admitted patients hospitalized for major depression10 reported that 25% met criteria for MD-Psy. In the Epidemiological Catchment Area Study,11 14% of patients who met criteria for major depression had a history of psychotic features. In a study composed of 18,980 people ages 15 to 100 who were representative of the general populations of the United Kingdom, Germany, Italy, Portugal, and Spain, 18.5% of those who fulfilled the criteria for a major depressive episode had psychotic features.12
The systematic study of MD-Psy has been limited by several factors, the first of which is that the disorder does not exist as a distinct diagnostic subtype in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).1,13 Also, very few psychiatric researchers have made the study of MDPsy a priority, and enrolling patients with this disorder in research studies may be difficult. Finally, the diagnosis is often missed by clinicians.9
DIAGNOSIS
According to DSM-IV criteria,13 one cannot make the diagnosis of MD-Psy unless delusions or hallucinations in the context of a major depressive episode are present. However, because the detection of delusions and hallucinations can be difficult in patients with MD-Psy,14 a number of research groups have explored whether there are other characteristics to help distinguish between patients with psychotic and nonpsychotic depression.
Several groups have reported that patients with MD-Psy demonstrate a more frequent and severe psychomotor disturbance (either retardation or agitation) than do patients with nonpsychotic depression.5,6,10,15-17 Patients with MD-Psy also have been reported to exhibit more pronounced paranoid symptoms,5,15 cognitive impairment,18-24 hopelessness,5 hypochondriasis,6,10 anxiety,6,17 early insomnia,5,15 middle insomnia,15 and constipation25 when compared with patients with nonpsychotic depression. In addition, MD-Psy patients do not show a diurnal variation in mood when compared with patients with endogenous nonpsychotic depression.25
DIAGNOSTIC ISSUES IN PSYCHOTIC DEPRESSION
Late-life Versus Young Life
Although the...