Missed diagnosis of psychotic depression at 4 academic medical centers.
BACKGROUND
Major depressive disorder with psychotic features (psychotic depression), though occurring relatively frequently in the general population, is a commonly missed psychiatric diagnosis.


OBJECTIVE
To ascertain accuracy of diagnosis of psychotic depression among inpatients at 4 academic medical centers and explore whether presenting symptoms, treatment setting, and physician's level of training affect the accuracy of diagnosis.


METHODS
The medical records of 65 patients who met DSM-IV criteria for psychotic depression following systematic assessment were analyzed to ascertain the concordance between chart diagnoses and research diagnoses arrived at using the Structured Clinical Interview for DSM-IV. The patients were participants in the National Institute of Mental Health Study of Pharmacotherapy of Psychotic Depression, conducted from December 28, 2002, through June 18, 2004, at 4 academic medical centers. For each patient's hospital visit, separate standardized data forms were completed on the basis of each physician's assessment of the patient prior to screening for the study. Hospital records from the emergency room and from admission to psychiatric units were reviewed. Among these 65 patients, 130 chart diagnoses had been made.


RESULTS
Psychotic depression had not been diagnosed prior to research assessments for 27% of the 130 diagnoses in our sample. The 3 most common diagnoses assigned to patients meeting research criteria for psychotic depression were major depressive disorder without psychotic features, depression not otherwise specified, and mood disorder not otherwise specified. Failure to identify psychotic depression was more likely when symptoms of depressed mood, hallucinations, or delusions were not noted in the medical record (all p < .005). The accuracy of diagnoses was greater on inpatient units than in emergency rooms (chi(2) = 7.64, p < .01).


CONCLUSIONS
The diagnosis of psychotic depression is frequently missed in emergency room and inpatient settings. The findings of this study are sobering given the serious morbidity and mortality of psychotic depression and the implications for treatment if an inaccurate diagnosis is made.


BACKGROUND
clinicaltrials.gov Identifier: NCT00056472.
Rothschild
Anthony J
AJ
Department of Psychiatry, University of Massachusetts Medical School, and UMass Memorial Healthcare, Worcester, MA 01605, USA. RothschA@ummhc.org
Winer
Jesse
J
Flint
Alastair J
AJ
Mulsant
Benoit H
BH
Whyte
Ellen M
EM
Heo
Moonseong
M
Fratoni
Susan
S
Gabriele
Michelle
M
Kasapinovic
Sonja
S
Meyers
Barnett S
BS
D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D000293:Adolescent; D000328:Adult; D003865:Major Depressive Disorder / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology; D003951:Diagnostic Errors; D039721:Diagnostic and Statistical Manual of Mental Disorders; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011618:Psychotic Disorders / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology