Clinical features of depression in remission of paranoid schizophrenia

Reasons for the development of depressive syndrome

The development of depressive syndrome in most people faced with this problem occurs against the background of psychological trauma. Events that are of the greatest value and significance for a person can significantly affect his psycho-emotional state. The psychological characteristics of the individual are of particular importance. Thus, some people endure stressful situations, while others experience anxiety, fear and worry.

Experts in the field of psychiatry note that the following factors have a serious impact on the psycho-emotional state of the patient:

long-term stress exposure;
serious illness, disability, loss of loved ones;
breakup, divorce;
conflict situations at work, change of team or dismissal;
significant deterioration in financial situation;
retirement;
change of place of residence, as a result of which a person cannot adapt.

In clinical practice, there are cases when signs of depressive personality disorder appear against the backdrop of successful achievement of a life goal. Experts explain this development of events by the fact that the patient had been striving to realize his ideas for a long time, making efforts to do so and using available resources. Such people often have limited interests and social contacts, and therefore subsequently cannot define a new goal for themselves and lose the meaning of life.

Depression may also be endogenous, caused by the action of neurochemical factors. Depressive syndrome can develop with mental illnesses such as bipolar personality disorder and schizophrenia. Mental disorders of this type occur as a result of metabolic disorders, leading to dysfunction of certain parts of the brain.

Components of the depressive triad

The classic depressive triad is characterized by such manifestations as abnormal anxiety, hopeless melancholy and constant apathy. Experts have developed a classification of this phenomenon, which is based on the nature and severity of motor and cognitive impairments:

the harmonious triad is distinguished by the predominance of cognitive impairments over motor ones;
the disharmonious triad is manifested by motor retardation, while cognitive processes deteriorate to a lesser extent;
a dissociated triad is characterized by a state in which emotional inhibition predominates; motor retardation or agitation may not be observed in patients.

Another classification, which is most widely used in psychiatry, includes disorders in the intellectual, affective and volitional spheres of the personality. This classification describes phenomena such as bradyphrenia, hypothymia and hypobulia.

The kraepelin triad in manic syndrome

Manic syndrome

– represented by the following triad of symptoms: a) painfully elevated mood (hyperthymia);
b) painfully accelerated thinking; c) psychomotor agitation. Patients assess the present and future optimistically, feel unusually cheerful, have a surge of strength, do not get tired, strive for activity, hardly sleep, but due to the extreme variability of cognitive processes with pronounced distractibility of attention, the activity is chaotic and unproductive. Increased activity can reach chaotic excitement ( confused mania ). Appearance of patients with mania: lively facial expressions, hyperemic face, rapid movements, restlessness, they look younger than their age. Patients tend to overestimate their own personality, their abilities, up to the formation of delusional ideas of greatness. Revitalization of the sphere of drives and impulses - increased appetite (eat greedily, swallow quickly, chew food poorly), sexual desire (easily engage in promiscuity, easily make unreasonable promises, get married).

Bradyphrenia

Bradyphrenia in modern psychiatry is defined as a general slowdown in the speed of mental processes, in which motor retardation may be observed. Patients experiencing this condition describe it as follows:

thoughts become constrained and confused;
there is a feeling of “emptiness in the head”;
Difficulties arise when establishing logical connections.

When observing such patients from the outside, you can notice that they sit motionless and look at one point. Bradyphrenia can also have various symptoms:

decreased speed of thought processes;
lack of motivation for mental activity;
difficulties in reproducing events and experiences from the past;
focus on your pathological condition;
superficial perception of current events and lack of interest in them;
having problems remembering information;
difficulties in formulating and expressing thoughts;
numerous reservations, typos and corrections in speech;
decreased social activity due to the fact that the patient cannot follow the train of thought of his interlocutors.

The complaints of depressed patients are often related to the absence of any thoughts. However, in this case, patients may spontaneously experience various associations and memories from childhood, which may be false.

In the absence of adequate treatment, bradyphrenia can reach its maximum intensity and lead to the fact that a person is unable to carry out everyday activities and solve emerging problems without the help of others. The greatest shock for patients is non-standard situations that require quick decision-making.

Hypobulia

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Another important component of the depressive triad is hypobulia. Patients in this state note that they experience suppression of any desire. With hypobulia, appetite decreases, patients can eat small portions in order to maintain physiological processes and ensure that the body receives the necessary nutrients.

A depressive state leads to the disappearance of sexual desire. In addition, patients stop caring for themselves and showing interest in their appearance, which is most pronounced in women. Another characteristic sign of depressive disorder is limited social contacts. The presence of other people and communication with them leads to serious difficulties and deterioration of mood, as patients prefer to spend time alone.

With hypobulia, patients pay special attention to their experiences and at the same time do not care about family and friends. A particular danger in this condition is suicidal thoughts, the occurrence of which is due to a weakening of the instinct of self-preservation.

The helplessness and inaction of patients cause them a feeling of shame, but the reluctance to take any action is stronger. Hypobulia can also be recognized by motor retardation, changes in handwriting, and slow gait. In addition, the facial expression of patients changes; it is distinguished by downturned corners of the mouth, a sad look, which reflects despair, melancholy and hopelessness.

Previous studies indicate that the incidence of depressive disorders in schizophrenia is very high - from 25 to 80% [3, 27]. Information about the frequency of depression at various stages of schizophrenia is contradictory. According to American authors [28, 34], it is most often detected at the stage of remission. The works of some domestic researchers [18] indicate that depressive disorders are most often identified in the premorbid and manifest periods of the disease.

It is known that the incidence of depression in the population is twice as high in women as in men. Therefore, female gender is one of the factors predisposing to the development of depression [6, 9, 12, 33]. However, this pattern is not observed in schizophrenia. There is also no consensus regarding the prognostic significance of depression in schizophrenia. Some authors [10, 23] consider depression that develops at the stage of remission as a risk factor for relapse of the disease and social maladjustment, while depression that develops during the period of stabilization of the mental state, without direct connection with productive symptoms, is assessed as a factor of favorable prognosis . There is also a point of view [17, 26] according to which, in schizophrenia, it is not the presence of depression, but its psychopathological structure that has prognostic significance.

To the above, we can add that there is no unified systematization of depression developing in schizophrenia [14, 15, 21].

The symptom complex “post-schizophrenic depression”, first described as an independent syndrome in 1969 by K. Heinrich and received official recognition only in ICD-10, does not add clarity to the understanding of the pathogenesis and classification of depressive conditions. Moreover, it was noted [8, 23] that such depression refers to a period of stabilization of the mental state rather than to remission itself. But some authors [8, 23, 24] distinguish between postpsychotic and postschizophrenic depression. If postpsychotic depression occurs during the period of remission immediately after the reduction of an acute psychotic attack, then postschizophrenic depression develops at a later (residual) stage of the disease, at least 6 months after the reduction of productive symptoms, during the period of final “stopping” and stabilization of the process. The terms “post-schizophrenic” and “post-processual”, without reflecting the essence of depressive disorders in schizophrenia, are not fully consistent with the criteria for post-schizophrenic depression according to ICD-10. In domestic psychiatry, since the 70s of the twentieth century, depression was described [1] in paroxysmal schizophrenia in the structure of the thymopathic type of remission, and various hypotheses for its development were put forward: depression as a stage of maturation of remission; as a new phenomenon caused by therapeutic pathomorphosis, indicating a regressive course of the disease with a complication of the remission structure and a simultaneous simplification of the attack picture [16]; as a manifestation of personality changes after an attack in the form of “acquired” circularity [15]. A diagnostic algorithm was proposed [19] aimed at recognizing depression at various stages of remission and optimizing therapeutic tactics.

There is also a point of view [22] that depression in schizophrenia is a comorbid mental pathology. In these cases, it often meets diagnostic criteria for a depressive episode, sometimes for subsyndromal depression.

The data regarding the relationship between depression and symptoms of schizophrenia are quite contradictory. Moreover, such symptoms (positive, negative, extrapyramidal, etc.) can cause depression and mask its manifestations [22, 30]. There are indications in the literature [20, 25, 30] on the need to distinguish between primary negative (deficit) and secondary symptoms that may be caused by depression, as well as on the connection between persistent depressive symptoms in chronically ill patients with schizophrenia and the severity of positive symptoms, social support, akathisia, demographic indicators, alcohol dependence, dosages of antipsychotics or correctors, negative symptoms, but the results obtained in this area are ambiguous. Domestic authors [22] noted that pharmacogenic depression can develop both in connection with extrapyramidal symptoms and without such a connection. There are also observations [32] that depressive symptoms can “cross” with negative manifestations and so-called silent parkinsonism.

Different points of view are expressed regarding approaches to the treatment of depressive disorders in schizophrenia, including those developing during the period of remission. Some authors [7, 10] point to the effectiveness of additional prescription of antidepressants, others [17] emphasize the ineffectiveness of such therapy.

Thus, the problem of depressive disorders arising from schizophrenia remains largely undeveloped and requires further study.

The purpose of this study is to study the clinical features of depression developing during the period of remission.

Material and methods

75 patients were examined, the average age of which was 44.9±1.22 years. Among them were 76% women. All patients suffered from paranoid schizophrenia with an episodic course (F20.01 and F20.02 according to ICD-10) and were in remission. The duration of remission at the time of observation was 2.84±0.27 years. In 78.7% of those examined, the duration of remission ranged from 1 to 3 years.

The duration of the disease was 16.79±1.03 years. The frequency of exacerbations of the disease in 50.7% of cases was less than once every 2 years. In 80% of cases, patients had a disability due to mental illness (76% of patients had group II).

The study used a psychopathological method and a number of psychometric scales: PANSS, Calgary scale, Hamilton anxiety scale (HAM-A), Barnes akathisia scale (BARS), Simpson-Angus assessment of neurological status (SAS), pathological involuntary movements (AIMS). Remission of schizophrenia was established in accordance with the criteria proposed by N. Andreasen et al. [29], which assume the absence or presence of mild symptoms (on the PANSS scale no higher than 3 points) for at least 6 months.

To analyze the primary data, descriptive statistics were used: determination of population averages and the standard error of the mean, calculation of the specific weight. Comparison of average values was carried out using methods of analysis of variance (for normal distribution) and determining the median for samples with non-normal distribution; Mean values were assessed using the Mann-Whitney U test. To assess the interdependence of data, the &khgr;2 criterion was used. A one-sided z test was used when comparing column proportions. To establish correlations, Spearman's rank correlation coefficient was used. p was considered reliable

0,05.

Results and discussion

The patients observed for 2 years were divided into 2 groups: the 1st consisted of 44 (58.7%) patients who developed depression, the 2nd - of 31 (41.3%) patients in whom remission occurred without depression.

In the majority of patients (63.3%) of group 1, the depressive state met the criteria for a mild depressive episode according to ICD-10 (F32.0). Moderate depression (F32.1) was observed in 36.4% of patients; There were no cases of severe depression.

Examination of patients using the Calgary scale confirmed the presence of depression, and in most patients the severity of individual symptoms did not exceed 2 points, which corresponds to a mild degree of the disorder (Table 1)

.
Patients complained of constant, distinctly depressed mood, feelings of hopelessness (from time to time or daily), ideas of self-deprecation and guilt (less than 50% of the time).
Blame ideas were either absent or unstable and persisted less than 50% of the time. Hypothymia, ideas of self-deprecation, feelings of hopelessness and early awakenings were more pronounced. In 36.4% of patients, the structure of depression was close to the “classical” endogenous variants [4, 5]. Vitalization of affect was observed in 30.8% of these patients, typical daily dynamics - in 76.9%.

In the majority (69.2%) of patients, suicidal thoughts were limited to discussions about the meaning of life, a passive desire to leave life and did not exceed a mild degree. The majority of patients (76.9%) were burdened by their condition and had a desire for treatment.

Depending on the characteristics of the thymic component of the depressive triad, the following variants of the described depressive states were identified: 1. Anxiety-depressive variant

(56.25%).
The severity of depression in this case reached moderate and mild degrees (63.6 and 36.4% of cases, respectively); 11.67±0.93 points on the Calgary scale. These cases met ICD-10 criteria for a depressive episode. 2. Depression with a predominance of melancholy - melancholic variant
(12.5%);
15.0±2.0 points on the Calgary scale. This depression met ICD-10 criteria for a moderate depressive episode. 3. Depression with a predominance of the apatho-adynamic component
(18.75%);
11.33±2.33 points on the Calgary scale. She met ICD-10 criteria for a mild depressive episode. 4. Mixed variants
, characterized by a combination of anxious, melancholy and adynamic components (12.5%; 10.0±2.0 points on the Calgary scale).

In 63.6% of patients, the depressive state was atypical, which was manifested in the uneven expression of the components of the depressive triad. There was no typical daily dynamics of the state, no vitalization of affect was observed. Characteristic features were the erasure of the thymic component, the predominance of apathy and irritability. The motor component of the depressive triad was characterized by either adynamic or asthenic coloration. Manifestations of ideation disorders ranged from a decrease in intellectual productivity to distinct thinking disorders combined with elements of depersonalization. There was no sufficient criticism of the depressive state; there was a passive, selective or evasive attitude towards treatment.

Suicidal tendencies were identified in 3.2% of patients. They were unstable in nature and were expressed in the desire to pass away from life in a passive way. Suicidal statements were manipulative and demonstrative in nature. In the structure of depression, there was a combination of depressive symptoms with residual psychotic disorders, and there were fragmentary paranoid ideas that were incongruent with depressive affect. These conditions did not meet ICD-10 criteria for a depressive episode.

Depending on the clinical picture, 6 variants of atypical depressive disorders can be distinguished: 1) a combination of depression with hypochondriacal experiences, senestopathies, depersonalization - 28.57% of patients; 10.0±0.82 points here and below on the Calgary scale; 2) depression with a predominance of the asthenic component - 14.29%; 10.5±2.18 points; 3) depression, in the structure of which the hysterical component clearly predominated - 3.57% of patients; hysterical phenomena occurred in the form of mild psychogenically provoked hysterodepressive states; 8.0±0.10 points; 4) depression, in which, against a background of low mood, persecutory delusional ideas incongruent with affect were observed - 17.86% of patients. There were ideas of attitude, fragmentary paranoid ideas, episodic verbal pseudohallucinations, which fit into the picture of the paranoid type of remission, did not have a significant impact on the patients’ behavior, and the leading complaints were of low mood; 9.80±0.97 points; 5) depressive states with obsessions - 7.14% of patients; 9.50±0.50 points; 6) mixed depressive states, in which apathy, hypochondriacal experiences, fragmentary ideas of relationship, depersonalization phenomena, anxiety were combined - 28.57% of patients; 9.13±0.90 points.

Patients with depression in remission of schizophrenia were also characterized by the presence of moderate anxiety symptoms (13.05±0.87 and 4.87±0.57 points on the HAM-A scale in groups 1 and 2, respectively ( p

0.001).
The combination of depression and anxiety was more often observed in patients with endogenous, close to classic variants of depression (36.4%). The mental state fit into the picture of anxiety-depressive syndrome and was characterized by decreased mood with irritability, loss of interests and the ability to have pleasure, ideas of low value, self-deprecation, premonition of trouble, threat, gloomy pessimistic vision of the future, increasing anxiety, anxiety in the afternoon (56.25 % of patients). A positive relationship was found between anxiety and depression ( r
= 0.735;
p
= 0.001), which confirms the hypothesis about the pathogenetic commonality of these two syndromes [2, 12-14, 27, 31, 34-36]. Among patients with atypical types of depression (63.6%), anxiety symptoms were observed in 28.57%. These patients were characterized by an unexpressed feeling of guilt, loss of meaning in life, anxiety for the fate of loved ones, combined with hypochondriacal symptoms. In the motor sphere, a combination of mild psychomotor retardation and fussiness was observed. Fragmentary ideas of relation were observed. The presented symptoms were combined with the phenomena of asthenia, loss of initiative, impoverishment of interests and narrowing of emotional contacts. Such states were characterized as anxious-apathetic.

A comparison of the selected groups showed that they were dominated by patients over 40 years of age, but among patients in group 1 with depression there were more young patients (18-29 years old) (Table 2)

, while women predominated in all age subgroups of these groups
(Table 3)
.

Among patients with depression, cases of hereditary burden of affective disorders (15.9%), alcoholism (34.1% of cases, p)

0.05). Patients in group 2 were more likely to have a hereditary history of schizophrenia (29.0% of cases). Suicidal behavior in relatives was detected only in the group of patients with schizophrenia and depression (20.5% of observations).

Patients of group 1 were characterized by a higher frequency of affective disorders in the prodromal period with the prevalence of anxiety-depressive syndrome, depressive-paranoid syndrome in the manifest period and during the last exacerbation of depression in the structure of an attack of schizophrenia. They were also characterized by violations of the treatment regimen. The duration of remissions remained unchanged and productive disorders became less pronounced during the course of the disease in both groups of patients (Tables 4, 5)

A history of affective disorders in the post-attack period was identified in 68.2%, and during the last exacerbation - in 27.2% of patients in group 1, and the diagnosis of “post-schizophrenic depression” in accordance with ICD-10 was not made. At the same time, antidepressant therapy with drugs from the group of TCAs and SSRIs was carried out in 75% of these patients. The duration of therapy was limited to the patient's stay in the hospital and the first month of observation after discharge to the psychoneurological dispensary.

When phenomenologically qualifying remission, the classification proposed by A.P. was used. Kotsyubinsky et al. [eleven]. In patients with depression (group 1), the asthenic type of remission was significantly more often observed, while in patients without depression, the paranoid type of remission was observed. Thymopathic and hypochondriacal types of remissions were found only in patients of group 1 (Table 6)

Shown in the picture

The data demonstrate the absence of significant differences in the comparison groups in the severity of positive disorders, as well as in clusters characterizing anergy, thinking disorder, and agitation.
Figure 1. Structure and severity of psychopathological symptoms according to the PANSS scale in patients with schizophrenia, depending on the presence of depression (in points).
Group 1 (with depression) had higher rates of general psychopathological syndromes and depression, while Group 2 (without depression) had higher rates of negative disorders and paranoid behavior.

Features of patient therapy are given in table. 7

As indicated in the table. 7

data, patients with depression more often received traditional antipsychotics, usually in the form of monotherapy, or were without antipsychotic therapy due to non-compliance.

Side effects of neuroleptic therapy during previous hospitalizations were noted by 79.5% of patients in group 1 and 35.5% of patients in group 2 ( p

0.05), while the presence of neuroleptic depression was not established.

As for the adverse events observed during maintenance neuroleptic therapy, which was carried out during the examination period, there were no significant differences between the groups in the presence and severity of akathisia, neurological side effects, and the overall severity of pathological involuntary movements, which did not exceed a mild degree. Patients in group 1 had more pronounced pathological jaw movements that did not cause distress (0.27±0.08 and 0.06±0.04 points on the AIMS scale; p

=0,037).

In 25% of patients in group 1, psychogenic symptoms that preceded the development of a depressive state were identified. Psychotraumatic factors, reflected in the structure of depressive experiences, were noted in 11% of cases in the subgroup of patients with atypical variants of depression in the structure of asthenodepressive and hysterodepressive states. Combinations of family conflicts, conflicts in the professional sphere, and material and everyday difficulties were more common (61% of cases). Family problems dominated in 17% of patients.

The data obtained confirmed the association of affective disorders during periods of exacerbation and during remission of depression in schizophrenia ( r

=0.374;
p
=0.001) [10].
The association between post-attack depression and depression during the remission of schizophrenia was also noted, which indicates the need for timely identification and adequate treatment of depressive disorders ( r
= 0.435;
p
= 0.001).
In remission of the apathetic, paranoid and autistic types, the probability of depression is lower ( r
= –0.249;
p
= 0.031), which corresponds to the opinion of some authors about the greater severity of deficiency symptoms in these types of remission [11, 21].
Indirect confirmation of the greater safety of patients with depression in remission of schizophrenia can be the inverse relationship between the severity of depression and negative symptoms ( r
= –0.289;
p
= 0.012), as well as thought disorders (
r
= –0.325;
p
= 0.004), which is not consistent with data on the absence [30] or the presence of a weak direct correlation [37] between depression and negative symptoms.
With an increase in productive symptoms and paranoid behavior, the severity of depression decreases ( r
= –0.253;
p
= 0.029 and
r
= –0.430;
p
0.001, respectively).
In the case of use of atypical antipsychotics, the risk of depression is reduced ( r
= –0.345;
p
= 0.002).
There were no statistically significant relationships between depression, akathisia ( r
=0.05;
p
=0.669), neurological side effects (
r
= –0.05;
p
=0.670) and pathological involuntary movements (
r
=0.088;
p
=0.459).

Summarizing the data obtained in this study, it can be noted that depression at the stage of remission of schizophrenia is observed in 58.7% of patients. The detection of clinically defined depression, including those with a complex psychopathological structure, in patients with paranoid schizophrenia does not exclude the presence of remission, which confirms the opinion of a number of authors [14, 21, 24] about the need to revise the criteria for remission of schizophrenia. Depressions in remission of paranoid schizophrenia are heterogeneous in structure and in 63.6% of cases are characterized by atypicality. The mechanisms of depression in remission of schizophrenia may be different; in 25% the disorders are psychogenic in nature. Comorbidity of depression with anxiety disorders (especially subsyndromal anxiety) is typical. Depression most often develops in women with schizophrenia over the age of 39 years, and in men - under the age of 39 years. Patients in remission of schizophrenia with depression are characterized by greater preservation of cognitive functions. Treatment with traditional antipsychotics is a risk factor for the development of depression in remission, regardless of the presence of side effects. When developing a set of measures for medical and psychosocial rehabilitation of patients with schizophrenia at the stage of remission, it is necessary to take into account the possibility of development and clinical diversity of depressive disorders.

Hypotymia

In a state of depression, patients experience low mood for a long period of time. This condition is called “hypotymia”; it is manifested by the absence of strong emotional reactions and reluctance to lead an active lifestyle.

Hypotymia, which precedes the development of depressive syndrome, develops gradually. It is a consequence of borderline mental states and the actions of numerous factors. This condition can occur in people after a suicide attempt, severe emotional shock, or with alcohol, drugs or other forms of addiction.

Hypotymia manifests itself in depressed patients with the following symptoms:

a sharp decrease in physical activity;
restriction of participation in public life;
lack of interest in physical and mental work, hobbies and usual activities;
decreased speed of mental processes;
impaired concentration and memory;
decreased self-esteem and ability to critically evaluate situations and one’s own actions;
pessimistic perception of the world;
the appearance of thoughts about the futility of the future.

Hypotymia can also have somatic manifestations, which include: pain in the chest and abdomen, constant weakness and apathy, eating disorders and changes in taste preferences, constipation or diarrhea, sleep disturbance. These signs indicate a pathological condition that requires professional treatment.

Forms of depression.

Depression falls into two main categories: unipolar and bipolar.

Bipolar depression is characterized by two alternating poles—mania and depression. Such ambivalence is characteristic of manic-depressive psychosis (MDP) and cyclothymia.

Unipolar depressions differ in that the patient’s mood remains within only one, depressed pole.

Types of unipolar depression:

Clinical depression (main and additional symptoms present).
Minor depression (two main symptoms are present for two or more weeks.
Postnatal depression (develops after childbirth).
Atypical depression (distinguished by the presence of both classic symptoms and signs uncharacteristic of depression - drowsiness, violent reaction to stimuli, increased appetite, etc.).
Dysthymia is characterized by a moderate decrease in mood, but for a long time (two or more years). Characterized by mild symptoms.
Recurrent depression is characterized by short-term depressive episodes (less than two weeks, usually a few days). However, for diagnosis it is necessary to have regular episodes for at least one year, without connection with the menstrual cycle, if the patient is a woman.

In addition, there is resistant depression, characterized by persistence

symptoms, despite treatment (more than 1.5-2 months). Resistance is usually explained by inadequate treatment, intolerance to prescribed drugs, addiction to them (increased tolerance), or individual personal and biological characteristics.