Depression in the Course of Schizophrenia

It is generally accepted that the first building block of modern psychiatric nosology was Kraepelin's distinction between those disorders we now know as mood disorders and the illness (or illnesses) we now know as schizophrenia. Nevertheless, beginning with Bleuler (1911/1950), the observation was repeatedly made over the years that a substantial proportion of patients diagnosed with schizophrenia manifest some sort of "depressive-like" symptoms at certain points during their clinical course. These two propositions were difficult to reconcile because the Kraepelinian dichotomy maintained a powerful influence in psychiatry and empirical observations and understanding of the depressive state in patients with schizophrenia were slow to accumulate.

The seeming non sequitur of "depressive" symptoms in schizophrenia, as a consequence of Kraepelin's original observations, generated a tendency either to ignore or to psychologize depressive states in schizophrenia in the early and middle years of the 20th century. In some psychodynamic writings, the question of depression in schizophrenia was written off entirely on the basis of a thesis that schizophrenia patients, by definition, lacked the proper ego structures to develop depression. Elsewhere in the literature, psychodynamic formulations were used to explain states of depression in patients with schizophrenia. Meyer-Gross wrote about depression as being a reaction of despair to the psychotic process and a denial of the future (see McGlashan and Carpenter 1976b).

Other central psychodynamic themes included loss (Miller and Sonnenberg 1973; Roth 1970; Semrad 1966) and the notion that a state of depression was a necessary stage in the progression out of the more pathological narcissistic regressed 31 state that was represented by florid psychosis (Semrad 1966).

Semrad (1966) also understood the depressed state to be influenced by the pain and/or despair of an "empty ego." Both he and Eissler (1951), however, saw depression in schizophrenia as a moment of therapeutic opportunity, when insight and mastery might overcome more primitive defensive psychotic ego states as they receded.

Differential Diagnosis of Depression in the Course of Schizophrenia

Medical/Organic Factors
A large number of medical/organic factors are possible as causes of depression in patients with schizophrenia (Bartels and Drake 1988). Obviously, any medical/organic factor that can lead to a depressive syndrome in an individual who does not have schizophrenia can also lead to a depressive state in a person with schizophrenia. Such possibilities include a number of common medical conditions (anemia, cancer, neurological disorders, infectious diseases, and metabolic or endocrine disorders), various medications used in the treatment of medical problems (antihypertensive medications such as beta-blockers, sedative-hypnotics, sulfonamides, and indomethacin), and discontinuation of other prescribed medications (most typically corticosteroids and psychostimulants).