In clinical practice, many schizophrenic patients are found to have anxiety and depression, but both family members and clinicians may only focus on psychotic symptoms (e.g., hallucinations, delusions, and behavioral symptoms) and ignore this problem, resulting in patients not being clinically cured and not being able to return to society.
In fact, anxiety and depression are common symptoms in patients with schizophrenia, but they are still under-recognized and under-treated. Kraepelin used affective symptoms as an important criterion to distinguish early-onset dementia from manic-depressive disorder, and also recognized the importance of depression as a symptom in schizophrenia and considered schizophrenia with severe depression as a subtype of the disorder; some scholars emphasized that despair is a psychological reaction that often appears in the acute psychotic phase. Some scholars emphasize that despair is a psychological reaction that often occurs in the acute psychotic phase; Bleuler, a well-known psychiatrist, considers depression as one of the core symptoms of schizophrenia. The clinical features of post-schizophrenic depression were described at the beginning of this century, but the concept was not formally mentioned internationally until ICD-10 and DSM-IV.
1. Depressive symptoms of schizophrenia and incidence of post-schizophrenic depression
In China, Wang Bo and Chen Yixian reported that the incidence of depressive symptoms in schizophrenic patients was 44.44% and 43.2%, respectively. The prevalence of depression after schizophrenia is not exact, but is estimated to be around 25%, with reports ranging from 7% to 70% in the literature. In a survey conducted by Liang Shaocai in 1000 schizophrenia inpatients in China, 270 cases (27%) were found to be depressed after schizophrenia.
2. Several conditions related to depression in schizophrenia
There are many different diagnoses of depressive symptoms in schizophrenia, including post-schizophrenic depression, schizoaffective psychosis, antipsychotic-induced depression, and a psychological response to schizophrenia, after all of these have been excluded,
Excluding all of these, depression is more likely to be part of the course of schizophrenia itself.
(1) Psychogenic reactions: Patients with schizophrenia have a heavy psychological burden, and psychological reactions of disappointment about life events are common. Some patients are in a chronic state of depression and disappointment, which are not easily distinguished from depression and are characterized by feelings of helplessness and hopelessness, lack of self-confidence and feelings of incompetence. In most cases, these psychological reactions cannot be explained by depression, and the process of psychological reactions is largely related to self-awareness.
(2) Negative symptoms: The negative symptoms of schizophrenia are clinically similar to depressive symptoms, and attempts are made to distinguish between the two types of symptoms,
The observed sadness is not a reliable evidence of depression, but the prominent subjective experience of depressed mood is suggestive of depression, while feeling helpless, hopeless, anxious, and suicidal thoughts point more to depression.
(3) Antipsychotic-induced: The role of antipsychotics in depressive symptoms in schizophrenia is controversial, but depression directly caused by antipsychotics is generally classified as pharmacogenic depression, with one theory being that the dopamine pathway plays an important role in reward and pleasure mechanisms, and another alternative theory being that antipsychotics induce pseudodepression due to motor inability and extrapyramidal responses. This phenomenon is known as “motor inability depression”, in which the patient acts like a “broken engine”, showing weakness, motor impairment, and sometimes a depressed mood. Johnson estimates that “motor inability depression” accounts for about 10-15% of depressive symptoms.
(4) Depression as a core symptom of schizophrenia: Depression can be a prodromal symptom of schizophrenia; some authors report that depressive symptoms occur in about 25% of patients in the acute phase of schizophrenia (within 6 months), so it is believed that depressive symptoms are very closely related to schizophrenia, and depressive symptoms are a core symptom of schizophrenia; Leff reports that depressive symptoms account for 4%-25% of chronic schizophrenia, with an average of (5) Post-schizophrenia
(5) Post-schizophrenic depression: While the term “post-psychotic depression” used to refer to a state of dysphoria immediately following a major psychotic episode, the DSM-IV currently recommends that “post-schizophrenic depression” be used to describe the presenting phase of schizophrenic psychosis The DSM-IV currently recommends that “post-schizophrenic depression” be used to describe depression that occurs at any time after the current episode of schizophrenia or even after a long period of time. In recent years, depressive symptoms in the chronic phase of schizophrenia have received close attention, and terms such as “postpsychotic depression,” “post-schizophrenic depression,” and “secondary depression” have been used to describe this phenomenon. The importance of depressive symptoms
3. The importance of depressive symptoms
Bleuler’s notion that prominent affective symptoms are a sign of a good prognosis for schizophrenia has persisted for many years, despite the lack of good evidence to support it, and evidence to the contrary has grown in recent years. Depression is an associated risk factor for death in schizophrenic patients, and approximately 10% of schizophrenic patients commit suicide. The majority of patients who commit suicide have a history of depression or current depressive symptoms.
In a 2-year follow-up study, Johnson found that depression prolonged the acute symptom period of schizophrenia by a factor of 2 and increased the risk of acute relapse of schizophrenia by a factor of 3; Falloon found that depression was the leading cause of hospital admissions by 40% and that depressed patients with schizophrenia were more likely to have a relapse of schizophrenic symptoms, These social impairments are also associated with post-schizophrenic depression, premorbid personality disorders, and insidious onset of illness.
Depressive symptoms are important in schizophrenia not only because they are related to the pathogenesis of schizophrenia and whether positive symptoms are active or quiescent, but also because they can worsen the patient’s psychological deficits,
as well as anticipating the patient’s attempted or completed suicide.
4. Causes of depression accompanying schizophrenia
The cause of depression as a core symptom of schizophrenia is unknown; Roy et al. have reported that early parental loss is associated with post-schizophrenic depression; Subotnik et al. have reported that post-schizophrenic depression is associated with a family history of positive affective disorder; recent studies have found that depressive symptoms are also associated with attention deficits, suggesting impairment of prefrontal function, and some reports have found that patients have an enlarged temporal lobe bilaterally, or possibly a reduced one; these findings These findings, as well as neurobiological evidence, are similar to those found in depression itself, and further research is needed to clarify this issue.
5. Diagnosis and treatment of depression accompanying schizophrenia
The assessment and treatment of depression in patients with schizophrenia has always been a clinical challenge, and recent advances in psychotropic medications and other treatments have highlighted the importance of early diagnosis; the goal of treatment is to substantially reduce the morbidity and mortality associated with depressive symptoms.
The first step in treatment is to rule out cases of schizoaffective disorder and treat them appropriately; second, consider and address any factors related to current medical and substance abuse, and if there is any evidence of antipsychotic-induced dyskinesia, reduce the dose of the medication or introduce an anticholinergic; dyskinesia is often accompanied by feelings of restlessness, and the presence or absence of medication should always be considered when the patient describes a depressed state of mind, Other management includes the use of beta-blockers (e.g., Zolpidem), benzodiazepines, and switching to another antipsychotic. If all of these factors are taken into account and the clinician is sure that the negative symptoms are not mistaken for depression, the choice of treatment should be based on the different stages of the disease.
In the early stages of depression, increased psychosocial support is thought to reduce the acute relapse of psychotic symptoms as an expected approach by the patient, and of course, if depression is a sign of acute relapse, antipsychotic medication should be used and increased, and early intervention in this sign of acute relapse may improve the prognosis. In the acute phase of schizophrenia, depressive symptoms should not be treated separately from other symptoms, and in most cases, depression can be successfully treated along with positive symptoms by increasing the dose of antipsychotic medication and enhancing psychosocial support, with hospitalization if necessary.
For example, olanzapine is more effective than haloperidol, and other atypical antipsychotics such as risperidone, ziprasidone, and quetiapine have mood-enhancing effects. Clozapine has been shown to reduce hopelessness, depression, and suicide in patients with schizophrenia. All trials of selective pentraxin recycling inhibitors (SSRIs) have shown good effects on depressive symptoms in schizophrenia, and in general, patients on SSRIs show improvements in all areas compared to placebo. However, because of the inhibitory effect of SSRIs on the CYP450 enzyme system, drug-drug interactions are more likely. The idea that electroconvulsive therapy (ECT) was previously used to treat patients with significant affective symptoms in schizophrenia may have originated from clinical observations in the 1940s (when ECT was the only effective method) that schizophrenia with significant affective symptoms was more effective, but a review of the literature from the 950s to the next two or three decades does not provide sufficient evidence that ECT is more effective in schizophrenia with affective symptoms. Some placebo-controlled studies from the 1980s to the present have shown that ECT is not significantly effective for depressive symptoms of schizophrenia, but rather for psychotic symptoms. Rehabilitation, social support, and work opportunities appear to reduce emotional depression in schizophrenia, and cognitive psychotherapy is also effective, although its role in the treatment of depressive symptoms in schizophrenia has not been investigated, and given its effectiveness in depression, its therapeutic role is worth exploring.
In summary, depressive symptoms are common in patients with schizophrenia, and depression in the early stages of the illness is more likely to be a psychological response to the illness, so psychological support in the early stages of schizophrenia is important; depression in the later stages of the illness is generally classified as post-schizophrenic depression, and depression itself is more likely to be one of the core symptoms of schizophrenia; although the cause of depressive symptoms in schizophrenia is not known, the prognosis of patients with depressive symptoms is not good. Early diagnosis and effective treatment can significantly reduce morbidity and mortality associated with depressive symptoms, and atypical antipsychotics can improve depressive symptoms while treating psychiatric symptoms, with SSRIs being the treatment of choice due to their positive efficacy and low toxicities. Cognitive psychotherapy is likely to be effective for depressive symptoms in schizophrenia and post-schizophrenic depression and deserves further investigation.