health.am

Substances of abuse, such as alcohol, cannabis, cocaine, and narcotics, can contribute to phenocopies of depression on the basis of acute use, chronic use, or discontinuation. Importantly, the discontinuation of two "legal" substances very commonly used by schizophrenia patients--nicotine and caffeine--can lead to withdrawal states that can mimic depression (Lavin et al. 1996). In particular, "smoke-free" and "decaf" policies on many inpatient units can lead to diagnostic confusion unless the possibility of withdrawal symptoms is considered in the differential diagnosis of "depressive" states.

Negative Symptoms of Schizophrenia Conceptually, the presentation of negative symptoms in patients with schizophrenia overlaps with the syndrome of depression in a number of domains (Andreasen and Olsen 1982; Bermanzohn and Siris 1992; Carpenter et al. 1985; Crow 1980; Siris et al. 1988a). Overlapping symptoms include poor energy, diminished interest, lack of pleasure, lowered drive state, reduced motor activity, impaired concentration, and general sense of helplessness. Other symptoms, however, may be helpful in making the distinction (Barnes et al. 1989; Kuck et al. 1992; Lindenmayer et al. 1991; Norman and Malla 1991). ....

Incidence and Prevalence of Depression in Patients With Schizophrenia

More than two dozen studies have been published examining the rates of occurrence of depression in the course of schizophrenia (Koreen et al. 1993; Sands and Harrow 1999; Siris 1991, 1995; Tapp et al. 1994). They have varied considerably in terms of a number of methodological considerations: the definition employed for schizophrenia, the definition used for depression, the interval surveyed, the methodology of the survey, and the patients' treatment status at the time of the observation. The most notable conclusion that can be drawn from these studies is that, no matter what definitions and conditions prevail, at least some meaningful rate of phenotypic depression is observed in the course of schizophrenia.

Among these studies, the rates of depression varied from a low of 7% in a cross-sectional assessment of patients with DSM-III-defined schizophrenia who were chronically hospitalized and in whom an effort was made to distinguish depression from negative symptoms (Hirsch et al. 1989), to a high of 75% for at least one positive assessment of depression by either one of two criteria among patients with "first break" RDC-defined schizophrenia who were evaluated on a weekly to monthly basis for up to 5 years (Koreen et al. 1993). The modal rate for all these studies was 25%, a fair benchmark that has endured through the course of a number of reviews (Johnson 1981b; Mandel et al. 1982; McGlashan and Carpenter 1976b; Siris 1991, 1995; Winokur 1972).

Since depression is observed more frequently in females among people without schizophrenia (Kessler et al. 1993), and since the expression of schizophrenia in general is different in women than it is in men in a number of ways (Goldstein and Link 1988), it would be interesting to know if sex differences are observed with regard to the presentation of depression in patients with schizophrenia (Goldstein and Tsuang 1990; Seeman 1997). Indeed, such differences, if found, would have theoretical nosological implications ...

Figure 2­1 depicts an integrative schema that conceptualizes the interplay of extrinsic and intrinsic factors with the schizophrenia diathesis. The basis for this formulation is the familiar stress-diathesis model of schizophrenia (Nuechterlein and Dawson 1984; Zubin and Spring 1977), supported by more recent understanding of the neuropsychological underpinnings of the pathophysiology of schizophrenia (Weinberger 1987).

In Figure 2­1, the vertical axis represents vulnerability to psychotic symptoms of the schizophrenic type and the horizontal axis depicts the proportion of the general population. At the far left, a tiny fraction of the population manifests a very high vulnerability to psychosis, with an everdecreasing loading for such risk moving to the right along the curve.

Figure 2­1. Model of vulnerability, stress, and schizophrenic diathesis.

Only a fraction of 1% of the population express a vulnerability so great that a schizophrenic psychosis will emerge under virtually any level of life stress, no matter how minor ...

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