Depressive symptoms in stable chronic schizophrenia: prevalence and relationship to psychopathology and treatment
Introduction
It has been recognised for many decades that depression of mood is a frequently occurring symptom in schizophrenia. Although Kraepelin (1917) used prominent affective symptoms as one criterion with which to separate dementia praecox and manic-depressive illness, he also identified several depressive subtypes of schizophrenia. Eugen Bleuler (1950) considered depression to be part of the core symptomatology of schizophrenia. While it is generally recognised that depression of mood is common in schizophrenia and is an associated risk factor for death by suicide (Roy, 1986), there is little agreement on its aetiology.
Depressive symptoms are most frequently associated with the acute phase of the illness, with studies suggesting a point prevalence as low as 22% (House et al., 1987) and as high as 80% (World Health Organisation, 1973). Lower rates of depressive symptoms are seen in the chronic phase of the illness, with a range of 4% (Addington et al., 1992) to 25% (Knights et al., 1979) and an estimated mean, for chronic in-patients, of 15% (Leff, 1990). Most of the reported studies on chronic patients to date did not define the clinical stability or chronicity of the patients involved. Further, previous studies of patients who were not in a state of acute relapse have also included patients in continuing care (long-stay) wards. Such a population does not necessarily help us in trying to understand depressive symptoms in today's population of patients, most of whom have had very different programmes of care and who have spent most of their ‘career’ in the community. Only one previous study (Pogue-Geile, 1989) described patients who were regarded as clinically stable and were living in the community, and found 9% to be currently depressed. Clinical stability was defined as: not hospitalised in the previous 6 months; no medication changes in the previous 6 weeks; and, judged by their psychiatrist to be stable.
The term ‘post-psychotic depression’ has been used to describe depressive symptoms arising during or after the resolution of a psychotic episode (McGlashan and Carpenter, 1978, Siris et al., 1988). The ICD-10 (World Health Organisation, 1992) definition of ‘post-schizophrenic depression’ avoids the issue of aetiology, describing this as a depressive episode, arising in the aftermath of a schizophrenic illness, with schizophrenic symptoms often still present but no longer dominating the clinical picture.
The first aim of this study is to ascertain the point prevalence of a state of ‘depression’ in otherwise clinically stable chronic schizophrenic patients in the community, using the ICD-10 approach to definition. The second aim is to examine the relationship between the depressive symptoms and other features of the illness, demographic variables and drug treatment. In addition, we sought to examine the extent to which depressive symptoms and negative symptoms overlap and whether use of certain rating scales makes differentiation easier.
Exploring the prevalence and associations of such symptoms in a clinically stable population of patients in the community may help to quantify the contributions made by various factors. We aimed to make our population relatively ‘pure’, so as to remove some of the confounding factors that can be difficult to account for in samples chosen in a less discriminating way. For example, it can be difficult to separate the effects of simply being in hospital from those of acute relapse.
Section snippets
Patient sample
One-hundred and twenty male and female patients, aged between 18 and 65 years, who met DSM-III-R criteria (American Psychiatric Association, 1987) for chronic schizophrenia, were recruited for the study. The patients were all outpatients attending clinics in two clearly defined geographical areas (Antrim and Ballymoney, Northern Ireland), which both include a town and its rural hinterland, in the year April 1993 to April 1994. The intention was to assess only those patients who were in a
Results
One-hundred and twenty patients were included in the study, 63 from the Antrim area and 57 from the Ballymoney area. Seventy-eight (65%) of the patients were male and 42 (35%) were female. Their mean age was 41.5 years (S.D. 11.2 years) with a range of 21–65 years. Ninety-eight of the patients were single (82%), 14 married (11.7%), 7 separated or divorced (5.8%) and one a widow (0.8%).
Discussion
The prevalence of depression found in this study (13.3%) falls close to the estimated mean of previous studies in chronic in-patient populations (Leff, 1990). It is somewhat higher than the rate of 9% found by Pogue-Geile (1989) in his smaller study of 44 stable chronic outpatients (four of whom had a diagnosis of schizo-affective psychosis), the only study with comparable methodology. In our study patients had been stabilised on their antipsychotic medication for 8 weeks as opposed to 6 weeks in
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