Clinical Symptoms and Treatment of Severe Depression - Melancholic and Psychotic Depression

[@katherinesadler5105]

Great video. I was diagnosed with severe depression with melancholic and psychotic features and put on a TCA and an antipsychotic, working like a charm and I have my life back. If you're interested, back in the olden days they distiguished between Melancholic depression and Atypical depression and used Amitriptyline (and nortriptyline) for Melancholic depression and the MAOI's for Atypical depression. This was before the advent of SSRI's/SNRI's etc. For me, Amitriptyline and Nortriptyline worked for melancholic depression when nothing else did. I truly believe Amitriptyline and Nortriptyline are the cure for Melancholic depression, however like you say if you have psychosis it's a good idea to add an AP in at the beginning.

[@PsychiatrySimplified]

Thank you for sharing your personal experience. You are correct about the difference between atypical and melancholic depression. This difference still exists and is taught. Nowadays augmentation strategies are considered to create broad spectrum ADs like TCAs and MAOIs with better tolerability in some. TCAs and MAOIs have good efficacy but have fallen out of favour due to tolerability issues in some patients but remain a key medication to consider in treatment resistance. We wrote this article covering many different augmentation strategies. psychscenehub.com/psychinsights/melancholic-and-psychotic-depression-diagnosis-and-management/

[@georamos4865]

Question? Did you use the Amitriptyline and Nortriptyline together or separately? Im asking because I too suffer from melancholic depression with psychotic features. And I want to ask my psychiatrist about starting one them. SSRIs have a horrible effect on me. :/

[@katherinesadler5105]

@@georamos4865 Hi, I used them separately. Amitriptyline metabolises into Nortriptyline in the blood, so they are a similar drug, but they have to be used separately. Hope this helps :)

[@georamos4865]

@@katherinesadler5105 Thank you so much. Im glad you were able to get your melancholic depression under control! What antipsychotic were you on if I might ask? Im on olanzapine

[@katherinesadler5105]

@@georamos4865 hi, I'm on lurasidone

[@dook2k]

Thanks!

[@PsychiatrySimplified]

Thank you for generosity

[@lisawest1556]

Thank you so much for this education Dr.

[@sunilgupta3687]

Amazing video.

[@PsychiatrySimplified]

Sunil Gupta thank you for your feedback 🙏

[@lakhvirsingh2749]

psychiatric diseases like Malenkholiya (melancholia), Mania (mania) Do you know what Humer is involved?

[@attheranch873]

Wow! Great information, thanks🌷

[@PsychiatrySimplified]

Glad you found it useful

[@xerxesgrant4431]

This video really helped me understand some symptoms of mental illness that I'm currently going through, so thank you so very much.

[@PsychiatrySimplified]

thank you for your comment. We really appreciate it and are pleased it helps you to understand the symptoms. We wish you well. We have outlined more detail here: psychscenehub.com/psychinsights/melancholic-and-psychotic-depression-diagnosis-and-management/

[@merindadiesel3370]

Thank you so much!

[@bs4893]

This is really interesting because I am currently experiencing agitated depression and I have been lucky enough to get a priority psychiatrist assessment booked due to being a clinician myself. A couple of years ago I had a facial palsy and a scan identified more white matter intensities than I should have for my age. I lost a lot of weight to look after myself and slow any progression but when I ask GP about it they say the scan likely not a good indication and not to worry about it? Thoughts?

[@PsychiatrySimplified]

Clinical symptoms should be the focus. The prescence of white matter hyperintensities should prompt 1. Proactive treatment or investigation of vascular factors 2. The depression is likely to be melancholic due to involvement of subcortical areas - involving cognition, activity, anhedonia dimensions. Hence the choice of AD to be broad spectrum usually. 3. Agitation / sleep dysfunction likely comorbid. 4. Obstructive sleep apnea can be comorbid here as it is a vascular risk factor The WMHs indicate a vulnerability and point to the nature of depresion and treatment. Ps not advice

[@Archie0pteryx]

Holy hell the intro is like an instant migraine generator

[@manishwahi7922]

Great job 👏👏👍👍

[@PsychiatrySimplified]

Thank you for your feedback 🙏🏼

[@stevensicherman4101]

From my reading, bipolar depression seems to be melancholic. Are these depressions, melancholic and psychotic many times bipolar, seeing that mood stabilizers and anti-psychotics useful in treatment? Thanks

[@PsychiatrySimplified]

Very good observation . Yes melancholic depression is a bipolar trait and should be treated as such . Melancholic and psychotic depression involves greater frontostriatal involvement while bipolar has a greater salience network abnormality in addition to the F-S dysfunction

[@Honest_review85]

Hello Dr. Talking from personal experience those worry ruminating obsessive guild thoughts e.t.c and hypodriasis wouldn't be reduced without an ssri. It would get worse with a tricyclic antidepressant. It would cause more agitation. A better aproach would be an ssri with lithium or seroquel. I'm curious why you believe norepinephrine and dopamine would reduce agitation and obsessive thoughts since instead of increasing it. I would appreciate your answer

[@PsychiatrySimplified]

The ruminations especially obsessional guilt or hypochondriacal overvalued ideation requires a low dose antipsychotic. this is why in melancholic or psychotic depression AD plus AP is usually considered together as only AD especially broad spectrum can worsen agitation. Subsequently treatment of the depressive components of psychomotor changes or cognitive changes require broad spectrum antidepressants. At milder levels SSRIs can be used. Lithium is considered second line if they do not respond to above. psychscenehub.com/psychinsights/melancholic-and-psychotic-depression-diagnosis-and-management/

[@Honest_review85]

@@PsychiatrySimplified Thank you very much 🙏

[@ricardoacedojr.4068]

Hi Dr. I have this kind of depression. I am taking Setraline 50mg and 50 mg amitriptyline and olanzapine at night would that be ok?

[@PsychiatrySimplified]

We cannot provide individual advice. This is best discussed with the doctor. In summary for melancholic or psychotic depression broad spectrum antidepressant plus antipsychotic is prescribed. In your case amitriptyline and sertraline combined can act as broad spectrum but risk of side effects should be monitored due to enzyme inhibition and increased serotonin. Clinical symptom improvement and side effects are best guide which should be discussed with the doctor. Ps not medical advice Article here psychscenehub.com/psychinsights/melancholic-and-psychotic-depression-diagnosis-and-management/

[@stevensicherman4101]

Thank you in advance. Is ECT effective when there may be an issue with dopamine receptors in the brain? Pre Parkinson’s perhaps

[@PsychiatrySimplified]

ECT can be used in Parkinson's disease in resistant depression, for example - but it depends on the indication and risk benefit analysis. in general, there are specific criteria for ECT to apply. psychscenehub.com/psychinsights/electroconvulsive-therapy-summary-of-ranzcp-guidelines/

[@stevensicherman4101]

Thank you so much, again

[@paleface5684]

Dr Rege I have 2 questions. You state that if agitation is there, then do have a high suspicion for psychosis and anti psychotics may have to be introduced earlier. Would the anti-psychotic be introduced earlier with a broad-spectrum antidepressant or without a broad spectrum antidepressant? You state that if “an antidepressant is prescribed, please do monitor for akathisia or worsening of agitation as it can be linked to poor outcomes”. Could you please expand on what you mean by this? Are your saying antidepressants can worsen MDD with Melancholic Depression and Psychotic Features causing akathisia? What type of antidepressants cause akathisia and what is the treatment if we see symptoms of akathisia (like rambling thoughts) after prescribing SSRI antidepressants to patients with psychotic depression?

[@PsychiatrySimplified]

Good questions : in context of agitation in MDD plus agitation - AD can lead to activation/akathisia - all ADS can do it - activating ones ( SNRIs, Bupropion etc more likely ) hence why first line treatment in Psychotic depression or agitated depression is AD plus low dose Antipsychotic. Important however is that if Depression with agitation only and no psychotic features present - in some cases sedative antidepressants e.g mirtazapine may help alone or AD plus short term benzodiazepine. The important point is that when patients are agitated a high suspicion for underlying psychosis should be kept. We discuss case studies in this article and discuss combinations also - psychscenehub.com/psychinsights/melancholic-and-psychotic-depression-diagnosis-and-management/

[@kratos8529]

@@PsychiatrySimplified does vortioxetine treat psychosis?

[@PsychiatrySimplified]

@@kratos8529 Vortioxetine is not an antipsychotic and is not a treatment for psychosis - it may be used as an adjunct to antipsychotic agents in some types of psychoses e.g depressive psychosis.

[@kratos8529]

@@PsychiatrySimplified what is the difference between psychosis and depressive psychosis?

[@stevensicherman4101]

We have begun in US accelerated TMS 10 treatments a day for 5 days theta burst. Any idea if that comes close to ECT?

[@PsychiatrySimplified]

ECT is a very different method - Electrical stimulus vs magnetic field. ECT is more potent than TMS - hence why TMS does not work very well in severe forms e.g psychotic depression. Unlikely that increased frequency of treatments will mimic ECT - as the area of stimulation continues to be DLPFC while ECT - is not as localised

[@stevensicherman4101]

Wish I had seen this before diving into TMS. Gave relief but shortlived. Healthy old guy, think I would be safe with high dose TCA?

[@PsychiatrySimplified]

There are many other options besides TCA for severe melancholic depression. A range of dual mechanism antidepressants or combinations can be used. Pls not medical advice. Your doctor will be in the best position to choose the right agent for you.

[@stevensicherman4101]

@@PsychiatrySimplified thank you very much

[@ricardoacedojr.4068]

How about waking at 4am with anxiety and agitation and it becomes better at night.

[@PsychiatrySimplified]

Better in the evening you mean? This is a pattern in melancholic depression - usually indicative of agitation with diurnal variation ( worsen in am better as day goes on)

[@leavesofchange]

I was diagnosed with this sort of stuff, i kept telling doctors it was something physically wrong. They implied that i must have a very severe delusion. Turns out i had a IgE wheat allergy. Took the wheat out of my diet, after the spasming stopped i had a full recovery. Brain fog lifted. Just saying.... doctors are sometimes wrong.

[@PsychiatrySimplified]

Thank you for sharing. Medical causes are important to rule out. Can you share what physical symptoms you were experiencing ?

[@leavesofchange]

@@PsychiatrySimplified at the beginning I lost 10kg in short space of time, I became hugely fatigued, sleeping for huge periods of time during day. I was groggy, headaches, couldn't focus. My appetite changed, I could eat half a meal before nausea and gagging, then about an hour later I would be so lacking in energy I would eat a whole bag of sweets and/or chocolates to perk me up so I could function. My body became frail and weak I couldn't pick up an ordinary box of possessions. I also had uncontrollable flatulence. I was told this was depression (in UK) and given anti-depressants. As the years went on my symptoms worsened - I became more tired, my G.I. symptoms worsened. I suffered night diarrhea 4 nights out of 7. my skins became full of rashes: my skin would just flake of like sandpaper, my mouth was so cut-up I stopped eating as food made it sting, my upper arms and thighs were covered in big black pock marks. And I had constant candida that left me in bed shivering with chills and flu.

[@PsychiatrySimplified]

@@leavesofchange sorry to hear and thanks for sharing. I’m surprised that that presentation was labelled depression without ruling out medical causes. How did you reach the final diagnosis ? What steps did you have to take?

[@leavesofchange]

@@PsychiatrySimplified Well the doctor did the blood screening for coeliac - and I was negative. this is generally where they leave it in UK. I had a gut feeling that something was wrong physically. so I asked my GP for a gastroenterology referral. she rolled her eyes at me and said "It's to do with the way you are feeling.". I demanded it. About a year later I had my Gastro appointment and the Gasotroenterologist said she had no idea why I was referred from the letter, I told her my symptoms, and she said said she would check me out for Crohn's and scheduled a colonoscopy. In UK you do a low-residue diet to prepare - so I ate no grains, no wheat. Day 3 my head cleared, all that fog in my head cleared like a miracle, and I started bounding about with unbelievable energy. Then on day 5 my body spasmed very badly, and my lower back was crippled with severe pain. I phoned up my gastro and she said we'd better test you for celiac. I refused. I spasmed continuously for 2 months, then after that I spasmed non-continuously. It's been 13 months - I still spasm, but it's less now. Anyhows, 3months into my wheat-free diet, I accidentally ate some wheat and had a severe IgE reaction resulting in hospitalisation. this happened a few times.

[@sirisaacnewton6396]

You're missing one very important part in the treatment of psychotic depression. Eliminating environmental psychosocial stressors comes FIRST before EVERYTHING else.

[@PsychiatrySimplified]

Appreciate your comment. Psychotic depression has a major biological weighting which means urgent biological treatments are a necessity. Delay can be serious. Most individuals have been trying environmental and psychological modifications for a long time - this is why recognising the different subsets of depression is crucial. Melancholic depressions when untreated for a long time can gradually progress if biological treatments are not considered early. Most of the population unless they are clinicians have not seen a psychotic depression. It is a medical emergency due to a high risk of suicide and can easily fly under the radar for a long time.

[@sirisaacnewton6396]

@@PsychiatrySimplified What's your email address? I've been studying psychotic depression for decades. I witnessed patients with psychotic depression in front of me for decades. I've watched patients with psychotic depression commit suicide while being prescribed SSRIs. I will send you EVIDENCE that you need to remove environmental psychosocial stressors when treating patients with psychotic depression. But you are right about one thing...clinicians need to watch for symptoms coming from akathesia

[@sirisaacnewton6396]

@@PsychiatrySimplified Psychotic depression has a major biological weighting which means urgent biological treatments are a necessity. But environmental psychological stressors trigger and exacerbate psychotic depressive "episodes". Ergo, a "combination" of both biological and environmental factors need to be taken into consideration when treating psychotic depression. I have EVIDENCE of what I am talking about

[@PsychiatrySimplified]

@@sirisaacnewton6396 Psychotic depression in the absence of Antipsychotic medication can lead to a worsening of symptoms. Ive covered these issues in this article - it’s a detailed article that also talks about akathisia agitation worsening with ADs in absence of APS. Case studies also there. You can write via the website email. psychscenehub.com/psychinsights/melancholic-and-psychotic-depression-diagnosis-and-management/

[@PsychiatrySimplified]

@@sirisaacnewton6396 yes absolutely environmental and psychological stressors exacerbate the condition and need to be addressed. I’ve actually covered that in the article in the slides where environmental and psychological issues are covered. psychscenehub.com/psychinsights/melancholic-and-psychotic-depression-diagnosis-and-management/

[@drkmn3628]

I THOUGHT HIS NAME WAS DR. SNAIL RAGE

[@PsychiatrySimplified]

Sometimes the autocorrect does that anyways 😁