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.

In this light, depression in the course of schizophrenia was seen as a significant positive prognostic sign. Clearly, though, in all these writings, depression tended to be seen not as a diathesis from which the patient was suffering, but rather as a reaction, in one form or another, to the primary illness of schizophrenia and/or its consequences. Little considered was the possibility that a natural diathesis for depression was complicating the course of schizophrenia in any substantial proportion of patients.

In more recent years, however, depression in schizophrenia became the subject of a more data-based approach to research. The frequency and intensity of depression have been documented in patients with schizophrenia (Bowers and Astrachan 1967; McGlashan and Carpenter 1976a; Siris 1991, 2000), as the definitions of both schizophrenia and depression have become more operationalized. In the latter part of the century, with the emergence of psychopharmacology as the central treatment modality for schizophrenia, the prognostic implications of depression appeared to change.