Depression in early psychosis is linked to poor outcome, relapse and risk of suicide, yet remains poorly understood. This article aims to examine the development of depression in acute and post psychotic phases of first episode psychosis (FEP), and its relationship to persecutors, voices, insight, and recovery. Data were gathered on 92 patients with acute FEP on depression course, severity and experience of positive symptoms, insight and appraisals of illness using validated semi-structured interviews and questionnaires. Measures were repeated at 12 months. Malevolent voices, use of safety behaviours and subordination to persecutors were associated with depression and suicidal behaviour in acute FEP. Loss, Shame, low level continuing positive symptoms and longer duration of untreated psychosis were associated with post psychotic depression. Negative appraisals remained stable despite recovery in other symptom domains. Thus, depression and risk in early psychosis may be propagated by the personal significance and content of positive symptoms experienced. When in recovery, low level symptoms, longer period of illness and negative appraisals are significant factors.
Depression in psychosis has clearly been identified as a significant predictor of unmet need (Landolt et al., 2012), and is strongly associated with poor outcome and suicide (Challis et al., 2013 and Upthegrove et al., 2010). Depression in the acute phase of schizophrenia often occurs at higher rates here than at other stages (Tapp et al., 2001), yet the relationship between depression and acute psychotic symptoms is poorly understood (Cotton et al., 2012). Much of the current literature focuses on the post psychotic or chronic phase of illness (Buckley et al., 2009), often with little distinction between the two. We have previously shown that depression in the prodrome to first episode psychosis (FEP) will convey an increased risk of depression and suicidal behaviour at future points, however also that depression can break through at any time unheralded by previous depression (Upthegrove et al., 2010). In post psychotic depression (PPD) few studies have focused on depression occurring after the first episode, however those that do show a higher rate of depression here than following relapse in established psychosis ( Upthegrove, 2009 and Upthegrove et al., 2010). Depression in schizophrenia and “non-affective psychosis” has been described as an intrinsic part of the syndrome itself, “revealed” as positive symptoms abate, or the result of anti-psychotic medication ( Siris, 2004). Whether there is overlap between depression and features of negative symptoms, for example ahedonia and lack of volition, has been debated for some time with authors concluding that it is possible to identify depression within non-affective psychotic illness ( Addington et al., 1992 and Siris, 2004). Yet whether depression with and without psychosis is driven by the same process is under-researched. We have yet to investigate the phenotype of depression in FEP in any real depth. A psychological model of post psychotic depression suggests a cognitive process of regained insight and appraisal of illness, and the impact of diagnosis as a label itself ( Birchwood et al., 2005 and Freeman and Garety, 2003). Recently increased interest has focused on the role of trauma for increasing the risk of affective instability and psychosis through enduring biological impacts ( Collip et al., 2013). Positive psychotic symptoms and illness appraisals can also provide fuel for this traumatic pathway, yet have not been studied in the acute phase, or to date in PPD following the first episode. The early years of psychosis remain high risk in terms of both suicidal behaviour and setting the trajectory for future functional outcome ( Crumlish et al., 2009 and Nordentoft et al., 2002). A fuller understanding of depression in FEP here has potential to translate in to more accurately targeted therapies and better outcomes for patients. This study aims to address this knowledge gap. Early psychosis, prior to longer term pharmacotherapy and during the first experience of acute psychotic symptoms, provides an ideal period to explore potential associations. We propose that psychological appraisals of positive symptoms and illness itself during this first experience will have maximum impact on the presence and persistence of depression.
