International Consortium for Psychotic and Bipolar Disorders Research, McLean Hospital, 115 Mill Street, Belmont, MA 02478-9106, USA.
J Clin Psychiatry. 2013 Jul;74(7):723-31; quiz 731. doi: 10.4088/JCP.12m08328.
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.
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.
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).
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.
从伴有精神病性特征的首发重性抑郁障碍（MDD）开始的纵向研究在年轻成年人中很少见；因此，在这项研究中，纳入了年龄范围较广的受试者。由于伴有精神病性特征的 MDD 可能在诊断上不稳定，因此我们系统地前瞻性评估了这些患者，从首发症状开始，以确定后来诊断改变的预测因素。
在这项前瞻性自然主义研究中，我们从 1989 年至 2003 年在马萨诸塞州和意大利的精神病住院病房招募了 DSM-IV-TR 伴有精神病性特征的 MDD 患者，并对他们进行随访，从首次住院开始，比较人口统计学、发病前和首发临床特征，以确定后来根据使用 DSM-III-R 患者版的结构化临床访谈进行诊断改变的预测因素。
在平均（SD）4.0（2.7）年的时间内，107 名年龄为 34.6（16.2）岁（范围为 10-82 岁）、经历首次终生 DSM-IV-TR 伴有精神病性特征的 MDD 发作的患者中，29.9%的患者诊断发生变化，转为 DSM-IV-TR 双相障碍（18.7%）或分裂情感障碍（11.2%）。与伴有精神病性特征的 MDD 稳定诊断相关的因素包括存在存在本体论痛苦（χ(2) = 13.8，P <.0001）、虚无妄想（χ(2) = 4.47，P =.034）和体重减轻（χ(2) = 4.69，P =.030）在首发症状出现时。预测双相障碍诊断的因素包括发病前冲动性（χ(2) = 9.10，P =.003）、ICD-10 混合状态（χ(2) = 19.4，P <.0001）和之前的轻躁狂症状（χ(2) = 13.7，P =.002）。预测后来诊断为分裂情感障碍的因素包括心境不协调的妄想（χ(2) = 9.17，P =.002）和体感幻觉（χ(2) = 9.53，P =.033）在首发症状出现时，以及之前的功能下降（χ(2) = 8.13，P =.008）、首发 Schneiderian 一级症状（χ(2) = 10.6，P =.005）和符合 ICD-10 分裂情感障碍标准（χ(2) = 24.9，P <.0001）。
在最初符合 DSM-IV-TR 首发伴有精神病性特征的 MDD 标准的患者中，早期出现与双相障碍或非情感性精神病相关的特征迹象，强烈预示着后来诊断为双相障碍或分裂情感障碍的变化。研究结果支持在提高复杂疾病的诊断和预后标准时，关注精神病理学细节的价值。
