Objective: The purpose of this study was to determine whether elderly
patients with psychotic depression differed in long-term outcome from
patients with nonpsychotic depression. Method: The study group consist
ed of 19 patients with psychotic major depression who had responded to
ECT (N = 15), nortriptyline and perphenazine (N = 2), or nortriptylin
e, perphenazine, and adjunctive lithium (N = 2) and 68 nonpsychotic de
pressed patients who had responded to either nortriptyline alone (N =
61) or nortriptyline and lithium (N = 7). All patients were maintained
on regimens of full-dose nortriptyline. When prescribed for the index
episode, adjunctive lithium was also maintained but perphenazine was
withdrawn 16 weeks after response. Patients were followed on a monthly
basis for 2 years or until relapse or recurrence, whichever occurred
first. Results: Patients with psychotic depression had a substantially
higher frequency of relapse or recurrence of depression and a shorter
time to these events than nonpsychotic depressed patients. At index a
ssessment, patients with psychosis were more severely depressed and ha
d had more prior episodes of depression, but these factors did not acc
ount for the difference in outcome between the two groups. Furthermore
, before entering the study, none of the psychotic patients had receiv
ed adequate treatment for the index episode of depression, and so thei
r pool outcome could not be attributed to prior treatment resistance.
Conclusions: Even when they achieved remission and were maintained on
a regimen of full-dose antidepressant medication, older patients with
psychotic depression were at greater risk of relapse or recurrence tha
n were their nonpsychotic counterparts. In particular, continuation/ma
intenance treatment with tricyclic monotherapy following response to E
CT had limited efficacy in this group of patients. These findings rais
e important questions about the optimal treatment of psychotic depress
ion in late life.