Psychotic depression, posttraumatic stress disorder, and engagement in cognitive-behavioral therapy within an outpatient sample of adults with serious mental illness

Depression with psychotic features afflicts a substantial number of people and has been characterized by significantly greater impairment, higher levels of dysfunctional beliefs, and poorer response to psychopharmacologic and psychosocial interventions than nonpsychotic depression. Those with psychotic depression also experience a host of co-occurring disorders, including posttraumatic stress disorder (PTSD), which is not surprising given the established relationships between trauma exposure and increased rates of psychosis and between PTSD and major depression.To date, there has been very limited research on the psychosocial treatment of psychotic depression; and even less is known about those who also suffer from PTSD. The purpose of this study was to better understand the rates and clinical correlates of psychotic depression in those with PTSD. Clinical and symptom characteristics of 20 individuals with psychotic depression and 46 with nonpsychotic depression, all with PTSD, were compared before receiving cognitive-behavioral therapy for PTSD treatment or treatment as usual. Patients with psychotic depression exhibited significantly higher levels of depression and anxiety, a weaker perceived therapeutic alliance with their case managers, more exposure to traumatic events, and more negative beliefs related to their traumatic experiences, as well as increased levels of maladaptive cognitions about themselves and the world, compared with participants without psychosis. Implications for cognitive-behavioral therapy treatment aimed at dysfunctional thinking for this population are discussed.