1. Depression in Schizophrenia:
Symptom, Syndrome
or Co-morbibidty?
E. Timuçin Oral
Assoc Prof of Psychiatry
Bakırköy Prof Dr Mazhar Osman State Hospital
for Research & Training in Neuropsychiatry
Istanbul / Turkey
2. Facts about Schizophrenia
Outcome
~15% fully recovered
~ 85% continue to have residual and/or active sx
~ 50% end up in hospital of day treatment
90% or more receive disability/welfare benefits or are
economically dependent
75% or more are unmarried
Approximately 10% die by suicide
Twice as likely as normal controls to die from other
causes
3. Facts about Schizophrenia
Culture:
Prevalence doesn‟t vary much (biological role?)
Content of delusions tends to vary cross culturally
Prevalence of schizophrenia seems to be higher in
lower SES communities (cause or the result?)
May impair occupational & social functioning
Increased stress + poverty may contribute to the
development
4. Schizophrenia: Course
Group 3
30% have repeated episodes of
illness with some impairment
between episodes
Group 2
25% have repeated episodes of
illness with no impairment
between episodes
Group 1
15% have only a single episode
of illness with no subsequent
impairment
Group 4
30% have repeated episodes of
illness with gradually declining
impairment between episodes
6. Schizophrenic Process
10 20 30 40 50 60
100%
Functioning
Age (yr)
Premorbid
Prodromal
Progression
Stabilization
Relapse
J. A. Lieberman.
7. DSM-IV - Schizophrenia
“The characteristics of Schizophrenia involve a
range of cognitive and emotional dysfunctions
that include perception, inferential thinking,
language and communication, behavioral
monitoring, affect, fluency, and productivity of
thought and speech, hedonic capacity, volition
and drive, and attention”
APA. DSM-IV-TR; 2000.
8. Comorbidity
Obsessive-Compulsive disorder
7.8% with schizophrenia had OCD
26% out of 50 patients met criteria for OCD
Depression
25% prevalence rate with Schizophrenia
Suicide
10% of patients commit suicide
Suicide attempts are 5 times higher than suicide rate
10. Depressive symptoms in
Schizophrenia
M=F
Main indication for 40% of hospital admissions
(Falloon et al, 1978)
Associated with poor outcome, personal and
social adjustment
Treatment non-compliance & increased risk of
suicide
(Carpenter et al, 1988)
14. Suicide & Schizophrenia
Male gender
Younger than 30
Depressive symptoms
Unemployed
Max 3 months after
discharge
Unadequate treatment
Paranoid subtype
Comorbid alcohol use
Adjustment problems
Akathisia
Nearly 10% of patients commit suicide:
15. Relationship Between
Schizophrenia - Mood Disorders / Suicide
CINP: Mood symptoms in schizophrenia are actually
a manifestation of schizophrenia rather than a
discrete mood disorder (Judd, 1998)
NIMH: Lifetime prevalence 1.5% (34 out of 20,291).
Judd: 91% accompanied by mental or substance
abuse disorders
NCS: 18.6% were schizophrenia without comorbid
mood disorders (59% comorbid UP; 22% comorbid BP)
16. Lifetime Suicide Rates (Judd, 1996)
UP (alone) 10,4%
Schizophrenia + UP 27,5%
BP (alone) 28,5%
Schizophrenia + BP 70.6%
37% at least one suicide attempt
7.9% in nonschizophrenic population (p<0.0001)
17. 40% reported suicidal ideation
23% reported suicide attempts
6.4% died
Patients who died had lower negative
symptom severity
Suspiciousness and Delusions were more
severe among suicides
Paranoid subtype: elevated risk (12%)
Deficit subtype: reduced risk (1.5%)
Fenton, et al. Am J Psychiatry, 1997
18. Finland National Project for
Prevention of Suicide
7% of all followed-up diagnosed as schizophrenia
78% attempted in active, 40% in acute phase
64% had depressive symptoms
40% were “violent”
21% had alcohol abuse
Age distribution was equal
Heilä, 1997
19. I am totally cured
doctor. I am not
paranoid anymore!
He is trying
to convince
me
20. Characteristic Symptoms
Schneider: specific types of delusions
and hallucinations
Bleuler: fragmented thinking, inability
to relate to external world
Kraepelin: emotional dullness,
avolition, loss of inner unity
21. Kraepelin:
The Borders of Schizophrenia
“…it is certainly possible that its borders
are drawn at present in many directions
too narrow, in others perhaps too wide.”
22. “Good Prognosis Schizophrenia”
Prominent affective symptoms
Acute onset
Family history of affective disorder
Good premorbid function
Presence of insight
23. Symptom Clusters in Schzophrenia
Affective
Depression
Anxiety
Aggression
Dysphoria
Psychomotor
activation
Cognitive
Learning
Memory
Attention
Executive
function
Language skills
Negative
Flattened affect
Anhedonia
Avolition
Social
withdrawal
Alogia
Positive
Hallucinations
Delusions
Bizarre
behavior
Thought
disorder
Agitation
24. Depression in Schizophrenia
Often been associated with
Worse outcome (5)
Impaired functioning
Personal suffering (6)
Higher rates of relapse, rehospitalization and
even suicide (10% of patients) (8,11,710 11, 13)
Literature on depression in schizophrenia is
imprecise whether the affect, symptom, or
syndrome of depression is involved.
25. Affect, Symptom, Syndrome?
Affect a mood state (happiness - sadness). Not
pathological as long as situationally appropriate
Symptom a sad mood state causes a distress. An
unwanted painful feeling a source of complaint.
Syndrome a complex of features includes
cognitive and vegetative features
pessimism, guilt, impaired concentration, lack of confidence, loss of
interest / pleasure, disturbances in sleep, appetite and energy level
Siris SG, Am J Psychiatry 2000; 157:1379–1389)
26. Differential Diagnosis of Depression
in Schizophrenia
1. Medical/Organic Factors
2. Negative Symptoms of Schizophrenia
3. Neuroleptic-Induced Dysphoria
4. Neuroleptic-Induced Akathisia
5. Reactions to Disappointment or Stress
6. “Postpsychotic Depression”
7. Prodrome of Psychotic Relapse
Siris SG, Am J Psychiatry 2000; 157:1379–1389)
28. Objective
To differentiate whether depression manifested as
only a cluster of symptoms, a syndrome or a co-
morbid disease in schizophrenia
97 out of 100 patients interviewed was participated
Inclusion Criteria
Receiving same medication >1 year
Exclusion Criteria
Other psychotic diagnoses,
Co-morbidity
AD, MS or ECT treatments in the last year
29. Scales
Structured Clinical Interview for Diagnosis (SCID)
Hamilton Depression Rating Scale (HDRS)
Calgary Depression Scale for Schizophrenia (CDSS)
Positive and Negative Syndrome scale (PANSS)
Definitions
Dx of MD (SCID) = „co-morbidity group‟
Scored > 8 (HDRS) + >12 (CDSS) = „syndrome group‟
Scored < 8 (HDRS) / <12 (CDSS) = „symptom group‟
Zero from all scales = „non-depression group‟
30. Patient Characteristics
47 Male (48,5%) and 50 Female (51,5%) patients.
Mean age = 38.24
59.8% single, 21,6% married and 16,5% divorced.
53,6% elementary school, 46,4% high school
82% unemployed, 15,5% still working
86,6% in middle, 11,3% in lower, 2,1% in higher
economic class
10,3% living alone
31. Illness Characteristics
71,1% paranoid
16,5% undifferentiated
8,2% residual
4,1% disorganized
Age of onset: 22,3
Age of treatment: 24,5
Median of hospitalizations: 3
Mean duration of remission: 22,5 months.
32. Group Characteristics
6 patients in co-morbidity group (6.2%)
10 patients in syndrome group (10.3%)
58 patients in syndrome group (59.8%)
23 patients in non-depression group (23.7%)
No gender, education, socio-economic and marital
status differences in between groups
Groups are identical in social support & SS coverage
90% of patients in co-morbid and syndrome groups
are unemployed
33. Suicide rates
2 in co-morbid group (33.3%)
2 in syndrome group (20%)
19 in symptom group (32.7%)
4 in non-depressed group (17.3%)
All patients were receiving SGA
40% of symptom group & 30% of non-depressed
patients were receiving clozapine
None of the patients were applied clozapine in co-
morbid group
34. 100% of comorbid group
90% of syndrome group
69% of symptom group
71% of non-depressed group
were diagnosed as paranoid sub-group
Depression in 1 and 2 relatives
4-6% in two groups
16.7% in co-morbid group
None in non-depressed group
35. Results
Frequency of depressive symptoms in
schizophrenia is very common while it is less
likely occurs as a syndrome or as an additional
diagnosis.
Defining depression and the severity of
depressive symptomatology is important in
schizophrenia as they may play a devastating role
in the course
