The differentiation of DSM-III-R psychotic depression in later life from nonpsychotic depression: Comparisons of brain changes measured by multispectral analysis of magnetic resonance brain images, neuropsychological findings, and clinical features

Background: Psychotic depression has been proposed as a distinct subtype of major depression. There is considerable evidence for this in younger patie nts, although the neuroimaging has been rudimentary. Volumetric imaging stu dies are required of consecutive cohorts of patients with depression. Methods: Ninety-nine consecutive elderly patients were diagnosed with DSM-I II-R major depression. Eighteen were psychotic, and 81 were not. Sixty-six patients were given a neuropsychological test battery, and 44 had a magneti c resonance imaging brain scan. A model integrating clinical, psychological , and neuroimaging findings for the explanation of delusion formation durin g depression is proposed. Results: Psychotic depression was characterized by worse physical health, m ore family history of depression, a poorer response to antidepressant drugs , and more severe lowering of mood; however, the strongest predictors of th e presence of delusions were diencephalic atrophy, reticular activating sys tem lesions, brain stem atrophy, and left-sided frontotemporal atrophy. The psychotic patients had poorer performance on tests of frontal lobe functio n and mental processing speed. Conclusions: In the elderly, psychotic depression is etiologically, clinica lly, and neuroradiologically distinct, and has different treatment requirem ents, from nonpsychotic major depression. (C) 1999 Society of Biological Ps ychiatry.