Psychiatry

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

5. Schizophrenia &
Related Disorders,
McKenna 2003
Oxford Press

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

9. Childhood Disorders Preceding
Schizophreniform Disorder (odds ratios)
Childhood anxiety
Depression
Conduct disorder
2.5
7.4
2.5
Schizophreniform
Disorder
Mania
2.1
3.3
2.5
Kim-Cohen et al 2003

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)

12. Pathologic Dimensions of Schizophrenia
Negative Symptoms
Affective flattening
Alogia
Avolition
Anhedonia
Social withdrawal
Positive Symptoms
Delusions
Hallucinations
Disorganized speech
Catatonia
Cognitive Deficits
Attention
Memory
Executive functions
(e.g., abstraction)
Mood Symptoms
Depression
Anxiety
Hopelessness
Demoralization
Stigmatization
Suicidality
Social/Occupational Dysfunction
Work
Interpersonal relationships
Self-care
Comorbid Substance Abuse

13. http://www.schizophrenia.com/schizpictures.html

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)

27. Antipsychotic Receptor Pharmacology
D1
D2
D4
5HT2A
5HT2C
Musc
a1
a2
H1
Haloperidole Klozapine
Risperidone
Quetiapine
Sertindole Ziprasidone Zotepine
Olanzapine

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