Predicting diagnostic change among patients diagnosed with first-episode DSM-IV-TR major depressive disorder with psychotic features.
OBJECTIVE
Longitudinal studies beginning from onset of major depressive disorder (MDD) with psychotic features in young adults are rare; therefore, in this study, subjects across a wide age range were included. Since psychotic MDD may be unstable diagnostically, we systematically evaluated such patients prospectively from first episode to ascertain predictors of later diagnostic change.


METHODS
In this prospective naturalistic study, we recruited patients with DSM-IV-TR psychotic MDD from 1989 through 2003 at psychiatric inpatient units in Massachusetts and Italy and followed them from first hospitalization to compare demographic, antecedent, and first-episode clinical characteristics for associations with later changes of diagnosis based on interviews using the Structured Clinical Interview for DSM-III-R, Patient Version.


RESULTS
Within a mean (SD) of 4.0 (2.7) years, diagnoses among 107 subjects aged 34.6 (16.2) years (range, 10-82 years) who were experiencing a first lifetime DSM-IV-TR psychotic MDD episode changed in 29.9% to DSM-IV-TR bipolar disorder (18.7%) or schizoaffective disorder (11.2%). Factors associated with stable diagnoses of psychotic MDD included ontological anguish (χ(2) = 13.8, P < .0001), nihilistic delusions (χ(2) = 4.47, P = .034), and weight loss (χ(2) = 4.69, P = .030) at initial syndromal presentation. Factors preceding diagnoses of bipolar disorder included antecedent impulsivity (χ(2) = 9.10, P = .003), ICD-10 mixed states at intake (χ(2) = 19.4, P < .0001), and previous hypomanic symptoms (χ(2) = 13.7, P = .002). Factors predicting later schizoaffective diagnoses included mood-incongruent delusions (χ(2) = 9.17, P = .002) and somatosensory hallucinations (χ(2) = 9.53, P = .033) at intake, previous functional decline (χ(2) = 8.13, P = .008), initial Schneiderian first-rank symptoms (χ(2) = 10.6, P = .005), and meeting criteria for ICD-10 schizoaffective disorder at intake (χ(2) = 24.9, P < .0001).


CONCLUSIONS
Among patients who initially met DSM-IV-TR criteria for first-episode psychotic MDD, early indications of features typically associated with bipolar disorder or with nonaffective psychoses, respectively, strongly predicted later diagnostic change to bipolar disorder or schizoaffective disorders. The findings support the value of psychopathological details in improving diagnostic and prognostic criteria for complex illnesses.
International Consortium for Psychotic and Bipolar Disorders Research, McLean Hospital, 115 Mill Street, Belmont, MA 02478-9106, USA. psalvatore@mclean.harvard.edu
Paola
P
Salvatore
Ross J
RJ
Baldessarini
Hari-Mandir K
HM
Khalsa
Mario
M
Amore
Cristina
C
Di Vittorio
Gabriella
G
Ferraro
Carlo
C
Maggini
Mauricio
M
Tohen
D000328:Adult; D003710:Demography; D003865:Major Depressive Disorder / Q000150:complications / Q000175:diagnosis / Q000523:psychology / Q000628:therapy; D003951:Diagnostic Errors / Q000517:prevention & control*; D039721:Diagnostic and Statistical Manual of Mental Disorders; D017050:Episode of Care; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D038801:International Classification of Diseases; D007558:Italy; D008137:Longitudinal Studies; D008297:Male; D008404:Massachusetts; D008875:Middle Aged; D011379:Prognosis; D011569:Psychiatric Status Rating Scales; D011599:Psychopathology; D011618:Psychotic Disorders / Q000175:diagnosis / Q000209:etiology; D012959:Socioeconomic Factors