Discussion

This study aimed to gauge the level of recognition and management approaches used by UK psychiatrists to manage and treat depression in psychosis. With depression in psychosis now being adopted in national and international clinical guidelines,^{Reference Dondé, Vignaud, Poulet, Brunelin and Haesebaert7} we wanted to explore whether any change in recognition has led to more effective management of depression in those with psychosis, particularly in the early stages of illness.

Overall, the majority of respondents (69.5%) indicated the use of antidepressant medication as a first line of treatment for young people with psychosis and comorbid depression. There was reasonable agreement among clinicians on the contextual factors and key symptoms that would prompt a prescription of antidepressant medication. For example, the majority of respondents reported low mood and anhedonia as the major symptoms for diagnosing depression (93% and 68%, respectively), with 45% also identifying anergia as a core symptom. Over 80% of participants reported that they would routinely prescribe a selective serotonin reuptake inhibitor (sertraline in particular). This indicates a reasonable agreement between clinicians on the best strategy for managing comorbid depression with psychosis. These findings demonstrate a possible shift in the management strategy since Siris et al's^{Reference Siris, Addington, Azorin, Falloon, Gerlach and Hirsch9} earlier publication, where a third of clinicians reported that they would rarely prescribe antidepressants in adjunct to antipsychotic medication.

Although previous studies have reported 70% prevalence rates of depression at illness onset,^{Reference Birchwood, Iqbal, Chadwick and Trower1} our study showed fewer respondents (19%) identified depression as occurring frequently in FEP; instead, 54% reported observing depression occurring with stable psychosis. This might suggest that depression in the early phases of psychosis is still underrecognised; this is concerning, given that young people in particular are at heightened risk of suicide within the first 12 months following the initial episode of psychosis.^{Reference Dutta, Murray, Hotopf, Allardyce, Jones and Boydell15,Reference McGinty, Sayeed Haque and Upthegrove16} However, it must also be acknowledged that the findings from our survey are reliant on the memory of clinicians, with a potential for recall bias, and so the accuracy of these findings may be challenged.

Despite a consensus on treatment strategies for depression, what became apparent from the survey was the uncertainty around assessing depression and delineating from psychosis symptoms, and particularly negative symptoms. Interestingly, a large proportion do not employ structured interview schedules to inform their assessment, which could aid this delineation. In particular, the CDSS was only used by 9% of respondents. The CDSS is a short and easily used instrument, designed specifically for the assessment of depression in psychosis, as it distinguishes between negative and positive symptoms.^{Reference Addington, Addington and Schissel17} Better promotion of these evaluation measures may be warranted.

There were also reports of challenges faced by clinicians in determining if the symptoms were part of an affective component of the psychotic episode, potentially highlighting the need for a better understanding of the diagnostic uncertainty and course of depression in early psychosis.^{Reference Upthegrove, Marwaha and Birchwood18}

Over the past two decades, there appears to have been a shift in prescribing of antipsychotic medications – particularly from the first generation (typical) to second generation (atypical) agents.^{Reference Leucht, Corves, Arbter, Engel, Li and Davis19} This is also reflected in our survey, where the majority were prescribing atypical agents such as aripiprazole, olanzapine, risperidone and quetiapine, compared with 4.9% and 3.9% of respondents prescribing haloperidol and zuclopenthixol. Thus, there appears to be a particular preference toward the antipsychotics believed to have the least side-effects, but not with recognition that some antipsychotics may have more antidepressant properties,^{Reference Goodwin, Haddad, Ferrier, Aronson, Barnes and Cipriani20} or possibly promote depression, such as haloperidol.^{Reference Barnes, Drake, Paton, Cooper, Deakin and Ferrier13}

In regards to coprescribing in the present study, most respondents reported that there were no combinations of antidepressants and antipsychotics that they would actively avoid; however, some did express actively avoiding citalopram and antipsychotic in combination, with some citing risk of prolongation of the corrected QT interval. A similar percentage reported they would actively avoid a combination of mirtazapine and olanzapine because of increased risk of weight gain and sedation. In line with this, the majority of respondents (>70%) stated that they provided routine physical health monitoring when coprescribing. These findings indicate that clinicians are perhaps more cognisant of the potential physical health problems caused by antipsychotic medications, and may suggest proactiveness in mitigating such risks. Although this finding is encouraging, recent data shows that only 32.3% of individuals with severe mental illness in England receive a full physical health check.^{Reference Butler, de Cassan, Turner, Lennox, Hayward and Glogowska21,22} Given the lowered life expectancy of individuals with schizophrenia, the current NICE recommendations advocate for annual physical health checks for all individuals with severe mental health problems.^{Reference Kendall, Hollis, Stafford and Taylor23} Improving physical health monitoring should remain a top priority.²²