Recognition and treatment of postpsychotic depression

Ten per cent or more of delusional disorder patients whose illness responds to neuroleptics experience significant degrees of mood disorder during recovery, sometimes very severe and with suicidal risk.(!0Z) Such postpsychotic depression has also been noted in recovering schizophrenics, or in a few cases, mania.

Various explanations have been proposed such as a medication side-effect or perhaps the achievement of insight which is painful. On the whole the most likely reason is neurochemical, due to rapid changes in neurotransmitter balance.

If the neuroleptic is withdrawn, the depression tends to improve but the delusions return. Therefore the proper approach is to continue with the minimum effective level of neuroleptic and to add an antidepressant drug in a full therapeutic dose. Occasionally, in extremely severe cases, electroconvulsive therapy is indicated. Subsequently the neuroleptic is continued but, in most instances, the antidepressant can be gradually withdrawn.

All cases of delusional disorder should be observed for the possible emergence of mood symptoms during recovery and treatment should be immediately instituted. If suicidal symptoms appear, admission for inpatient observation and treatment is highly recommended.

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