Treatment of mood-congruent psychotic depression with imipramine

Background: Most studies report a poor response of psychotic depressed pati ents to treatment with a tricyclic antidepressant alone compared to combine d treatment with an antipsychotic preparation and compared to non-psychotic depressed patients. However. the issue of optimal treatment of psychotic d epressed patients has not been resolved as yet. Previously, we reported a s ignificant difference in response to mirtazapine compared to imipramine in a randomised, double-blind. fixed-blood-level study with in-patients with m ajor depression. In the current study we focus on the treatment response to imipramine in a group of patients with psychotic depression and compare th is to patients who manifest no psychotic features. Our aim in presenting th ese findings was to contribute to the discussion on the optimal treatment o f psychotic depressed patients. Methods: Fifty-two patients with a unipolar major depression (DSM-IIIR), comprising 15 patients with mood-congruent ps ychotic features and 37 patients with no psychotic features. were commenced on treatment with imipramine after a drug-free and placebo-washout period of 7 days. The dose of imipramine was adjusted for all patients to a predet ermined blood level. The Hamilton (HRSD) and Montgomery-Asberg (MADRS) Depr ession Rating Scales were used to evaluate treatment response. Results: Of the 45 patients who completed the study, nine of the 13 psychotic patients (69.2%) and 14 of the 32 non-psychotic patients (43.8%) responded to treatm ent. The patients with psychotic features demonstrated a lower mean final H RSD score. together with a greater fall in MADRS score over time, compared to the noti-psychotic group. Both these findings remained statistically sig nificant after controlling for a number of possible confounding factors. Co nclusions: These results demonstrate that, in this group of patients with m ood-congruent psychotic depression. imipramine used on its own together wit h strict control of serum drug levels produced a high treatment response ra te of 70%. Clinical implications: If replicated, these findings suggest tha t imipramine with control of blood levels of medication may be a useful fir st-line treatment for depressed patients with mood-congruent psychotic feat ures. Limitations: Our sample size was modest. This fact may caution agains t generalisation of the results. (C) 2001 Elsevier Science B.V. All rights reserved.