The treatment of psychotic depression: is there consensus among guidelines and psychiatrists?

Psychotic depression (PD) is a prevalent, severe, under-diagnosed and often inadequately treated mental disorder, which has received disproportionally little attention by clinicians, researchers and the pharmaceutical industry. Consequently, the evidence base for optimal clinical practice regarding PD is limited. The aim of this study was to investigate the degree of consensus among international treatment guidelines on PD and to determine whether a potential lack of consensus would be reflected in the clinical practice of Danish psychiatrists.

1. Review and comparison of international guidelines on the treatment of PD. 2. Questionnaire based survey regarding Danish psychiatrists' treatment of PD.

The nine international treatment guidelines considered in the review have contrasting opinions on the optimal treatment for PD: 6 of 9 suggest antidepressant (AD)+antipsychotic (AP) combination therapy, 3 of 9 recommend AD monotherapy and 5 of 9 find electroconvulsive therapy (ECT) equally appropriate as first line treatment. The 113 surveyed psychiatrists displayed the same lack of consensus. Their preferred treatment was either AD+AP combination therapy (42%), AD monotherapy (31%) or ECT (21%). The first line choices of ADs and APs were tricyclic antidepressants (51%) and quetiapine (62%), respectively.

The survey data are subjected to a potential selection bias as the respondents are likely to represent the more informed fraction of psychiatrists.

Our results indicate that both treatment algorithms and clinical practice regarding PD are highly heterogeneous. This finding emphasizes the need for further studies on the treatment of psychotic depression.