Acta Psychiatr Scand 2000: 101: 153±160 Copyright # Munksgaard 2000

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ACTA PSYCHIATRICA
SCANDINAVICA
ISSN 0902-4441

Prevalence and background factors

of depression in ®rst admitted
schizophrenic patients
Bottlender R, Strauû A, MoÈller HJ. Prevalence and background factors R. Bottlender, A. Strauû,
of depression in ®rst admitted schizophrenic patients. H. J. MoÈller
Acta Psychiatr Scand 2000: 101: 153±160. # Munksgaard 2000. Department of Psychiatry,
Ludwig Maximilians University,
Objective: The aim of this study was to investigate the prevalence and Munich, Germany
background factors of depression in ®rst admitted schizophrenic
patients.
Method: The study is an analysis of 998 consecutively admitted
schizophrenic patients with their ®rst hospitalization. Patient's char-
acteristics were prospectively assessed using standardized instruments at
the time of ®rst admission and discharge.
Results: High prevalence rates of depressive symptoms were found.
Depressed schizophrenic patients were more likely to have suicidal
tendencies, were older, more frequently married, less frequently single
and unemployed and had more family members with psychiatric
disorders other than schizophrenia than the non-depressed patients. Key words: depression; extrapyramidal symptoms;
Positive, negative and extrapyramidal symptoms do not have a negative symptoms; positive symptoms;
schizophrenia
substantial in¯uence on depression in these patients.
Conclusion: The study suggests that depression represents a distinct Ronald Bottlender MD, Department of Psychiatry,
psychopathological dimension of the acute illness in ®rst admitted Ludwig Maximilians University, Nussbaumstr. 7,
schizophrenic patients. In particular, in light of the suicidal tendencies, D Ð 80336 Munich, Germany
recognition and treatment of depression is an important clinical task. Accepted for publication July 19, 1999

Introduction cated that depression during the acute phase of

Schizophrenia is a heterogeneous disorder with a
plethora of psychopathological features, including
positive, negative and also affective symptoms.
Despite differences concerning the prevalence rates
of depressive symptoms between different studies, it
is generally accepted that depressive symptoms in
schizophrenia are common and often severe (1±3).
Depressive symptoms in schizophrenic patients may
be present before or during a patient's hospitaliza-
tion for a psychotic episode or occur after recovery
from the acute episode (4). The prognostic relevance
seems to depend upon the stage of illness at which
the patients were assessed. Depression in the
chronic course of schizophrenia often appears to
be an unfavourable sign (1, 5) and has been
associated with a greater risk for suicide (6) and
relapse (7). Contradictory reports, however, indi-
schizophrenia may be associated with favourable
prognosis and remission (8, 9). Aetiological theories
of depression in schizophrenia are controversial and
include effects of neuroleptics, psychoreactive and
other secondary causes (10). Some recent evidence
also supports the hypothesis that depressive symp-
toms are an integral part of schizophrenia (1, 11).
To summarize, there are good reasons to assume
that depression in schizophrenia is unlikely to have
a single aetiology. The still ongoing controversy
about the topics mentioned above indicates that
empirically based knowledge about depression in
schizophrenia and its background factors is worth
developing.
On the basis of our extensive documentation
system, including psychopathological data as well
as sociodemographic data, we wanted to address the

153
Bottlender et al.
following questions: (i) what is the prevalence of
depressive symptoms and suicidal tendencies in ®rst
admitted patients with schizophrenia at the time of
admission and at discharge? (ii) what is their
relationship to the diagnostic subtype of schizo-
phrenia, the duration of symptomatology before
admission, negative and positive symptoms and
acute outcome? (iii) do sociodemographic para-
meters contribute to depression in schizophrenia?
and (iv) is there a genetic background for depressive
symptoms in schizophrenia?
Material and methods
All patients of the study were consecutively
admitted in-patients of the psychiatric hospital
of the Ludwig-Maximilians-University, Munich.
Patients ful®lled the following inclusion criteria:
N diagnosis of a schizophrenic disorder according to
ICD-9 (ICD-9: 295.0±295.9, with exclusion of
295.7 (schizoaffective disorder));
N ®rst admission during the period of 1980 until
1995.
Assessment of psychopathological symptoms
Psychopatholgy was assessed prospectively in a
standardized manner by using the AMDP system.
The rating is evaluated during the ®rst day of the
admission and on the last day of the hospital stay.
All assessments were performed by experienced
resident psychiatrists. Psychopathological rater
training was performed regularly to establish a
high inter-rater reliability. The AMDP system has
been developed in Europe by the Association for
Methodology and Documentation in Psychiatry
(AMDP) to standardize the documentation of
psychiatric ®les. It is a comprehensive rating
instrument which is based on traditional descriptive
psychopathology and covers all the psychopatho-
logical manifestations of functional psychoses (12,
13). As well as the psychopathological symptoms
the AMDP also contains a section with somatic
symptoms, including disturbances of sleep and
vigilance, appetite disturbances, gastrointenstinal
disturbances, cardiorespiratory disturbances, other
autonomic disturbances or somatic disturbances
and neurological disturbances. Each item of the
AMDP can be graduated on a four-point (0±3)
scale. Pietzcker et al. (14) extracted several psycho-
pathological syndromes by using the principal
component analysis of AMDP ratings. Psycho-
social functioning was recorded by the Global
Assessment Scale (GAS, (15)). This is a single-
dimension rating scale for the evaluation of the
overall functioning of a subject on a continuum,
154
from severe psychiatric sickness (rated 0) to health
(rated 100). The GAS has 10 behavioral de®nitions,
one for each 10-point interval. It is not in¯uenced
by consideration of prognosis, previous diagnosis or
the presumed nature of the underlying disorder.
De®nition of depressive symptoms and syndromes
For assessment of depression, the summary score
for the depression syndrome of the AMDP was
calculated (14). This syndrome includes the items
depressed mood, hopelessness, inhibition of drive,
rumination, feeling of loss of feeling, loss of vitality,
feelings of insuf®ciency, feelings of guilt, worse
mood in the morning, interrupted sleep, shortened
sleep, early wakening and decreased appetite.
A depressive symptomatology was judged to be
clinically signi®cant when the symptom `depressive
mood' was present and furthermore the summary
score of depressive syndrome was eight or higher.
This cut-off score was chosen as we found in
another analysis of our data that the respective
summary score of 90% of patients with the
diagnosis of a major depression (ICD-9: 296.1)
lies above this score (unpublished data).
Further psychopathological syndromes which
were taken into account in our analysis were the
positive syndrome (14) and the negative syndrome
(16). Items of the positive syndrome are delusional
mood, delusional perception, sudden delusional
ideas, delusional ideas, systematized delusions,
delusional dynamics, delusions of reference, delu-
sions of persecution, verbal hallucinations, bodily
hallucinations, depersonalization, thought withdra-
wal and other feelings of alien in¯uence. Items of
the negative syndrome are disturbed concentration,
inhibited thinking, retarded thinking, restricted
thinking, thought blocking, incoherence, feeling of
loss of feeling, blunted affect, parathymia, affective
rigidity, lack of drive, mutism, social withdrawal
and decreased libido.
Extrapyramidal symptoms were part of the
AMPD section including somatic symptoms. For
calculations in this study, summary score of the
following items was determined: rigor, tremor,
acute dyskinesia, hypokinesia and akathisia.
Information about the sociodemographic data
(age, gender, marital state, etc.), psychosocial
stressors before admission, ®rst onset of the
illness, duration of symptoms before admission
and family history of psychiatric disorder were
derived from the computerized documentation
system of our hospital. The documentation of
these data is operationalized. For example,
psychosocial stressors were assessed for the
3-month period before admission and documented
as `non-existent=0', `questionable existent=1',
 Factors of depression in schizophrenic patients

`existent=2' and `unknown=3'. Family history of
psychiatric disorder is documented as `same
psychiatric disorder is existent in the patient's
family=1', `other psychiatric disorders are exis-
tent in the patient's family=2', `psychiatric
disorders are existent in the patient's family, but
the speci®c nature is unknown=3', `there are
different kinds of psychiatric disorders in the
patient's family=4' and `a history of a psychiatric
disorder is not known in the patient's family=5'.
Statistical analyses were carried out using the
SPSS 7.5 Software for Windows. Group differences
for psychopathological data and age were com-
pared by using the t-test. Group differences on all
categorical variables were evaluated using the x2
statistics. For calculation of correlations the
Pearson correlation index was calculated. A P-
value of <0.05 (2-tailed) was considered statisti-
cally signi®cant.
Results
In total, 998 ®rst admitted patients from the years
1980±95 (487 females (mean age=34.19t11.90
years), 511 males (mean age=27.54t8.29 years))
with the diagnosis of schizophrenia according
to ICD-9 criteria were included in the study.
Information about the different subtypes of schizo-
phrenia can be drawn from Table 1.
Depressive symptoms and suicidal tendencies in schizophrenia
at the time of admission
Results concerning the depressive symptomatology
were as follows: mean summary score of the
depression syndrome for the total of 998 patients
was 4.57 (t4.27). Twenty-one per cent (210 cases)
of all patients reached a summary score of eight or
higher. The symptom `depressed mood' was present
in 38.9% (388 cases) of the patients, whereby mood
was slightly depressed in 14.4% (144 cases),
moderately depressed in 19.2% (192 cases) and
severely depressed in 5.2% (52 cases). A clinically
signi®cant depression according to our de®nition
(see Material and methods) was detected in 15, 5%
(155 cases) of all patients (see also Table 2).
Frequency of psychosocial stressors, which may
have contributed to the depressive symptomatol-
ogy, was comparable for both groups in the
3-month period before admission. The same was
found for the duration of symptoms before admis-
sion (including affective and psychotic symptoms),
which has shown no signi®cant differences between
depressed and non-depressed schizophrenic patients
(see also Table 5).
Suicidal tendencies were present in 21.8% of all
patients. Signi®cant differences were found between
the depressed and non-depressed patients (40% vs.
18.5%). In depressed patients, suicidal tendencies
were slightly expressed in 17.4% of the cases (non-
depressed group=10.6%), moderately expressed in
14.8% (non-depressed group=6.2%) and severely
expressed in 7.7% (non-depressed group=1.8%).
Signi®cant differences between both groups for
suicide attempts in the past history were not found
(see also Table 2).
Contribution of negative, positive and extrapyramidal symptoms
to depression in clinically signi®cant depressed schizophrenic
patients
Analysis of the contribution of negative, positive
and extrapyramidal symptoms to depression was
carried out in three steps. In the ®rst step,
correlation between the summary scores of the
different syndromes at time of admission was
calculated. In the second step, we investigated the
correlation between the depressive syndrome and
single symptoms of the negative, positive and
extrapyramidal syndrome. In the last step, correla-
tion between the changes in the different syndromes
between the time of admission to discharge was
determined. The corresponding results of these
analyses are presented in Tables 3 and 4. These
results indicate that there are no signi®cant inter-
actions between the depressive syndrome at admis-

Table 1. Characteristics of patients with different diagnostic subtypes of schizophrenia

Frequency of clinically
Diagnostic Number Age Gender depressed patients number
subtype ICD-9 (% of total) (meantSD) (female/male) (% within the subtype of schizophrenia)

Simple type 24 (2.4) 30.17t10.39 10/14 2 (8.3)

Hebephrenic type 170 (17) 22.82t3.46 51/119 18 (10.6)
Catatonic type 68 (6.8) 27.09t8.38 27/41 8 (11.8)
Paranoid type 424 (42.5) 34.43t11.45 217/207 71 (16.7)
Acute schizophrenic episode 249 (24.9) 30.16t9.70 149/100 47 (18.9)
Latent schizophrenia 10 (1) 28.70t10.86 7/3 3 (30.0)
Residual schizophrenia 27 (2.7) 38.74t10.59 11/16 2 (7.4)
Other speci®ed type 16 (1.6) 30.50t13.52 11/5 2 (12.5)
Unspeci®ed type 10 (1) 34.60t9.67 4/6 2 (20)

155
Bottlender et al.

Table 2. Comparison of psychopathological features distinguishing between schizophrenic patients with and without clinically relevant depression

Patients with Patients without

Characteristics depression depression Signi®cance1

Number (% of total) 155 (15.5) 843 (84.5)

GAS admission (meantSD) 34.07t13.09 34.48t12.41 NS
GAS discharge (meantSD) 61.15t14.75 57.76t16.19 0.010
Depression syndrome at admission (meantSD) 11.68t3.99 3.26t2.76 <0.001
Depression syndrome at discharge (meantSD) 2.31t3.02 0.77t1.36 <0.001
Frequency of suicidal tendencies (%) 40 18.5 <0.001*
Frequency of suicide attempts in past history (%) 9 6 NS*
Negative syndrome at admission (meantSD) 10.75t5.35 8.85t5.13 <0.001
Negative syndrome at discharge (meantSD 3.72t3.63 3.93t3.86 NS
Positive syndrome at admission (meantSD) 11.08t6.83 9.94t6.75 NS
Positive syndrome at discharge (meantSD 1.66t3.56 1.84t3.69 NS
1
Statistical analyses were performed by using the 2-tailed t-test for independent samples or the x2 statistics; the latter is indicated by*.

sion and the positive, negative or extrapyramidal
syndrome at admission (Table 3). Analyses of the
changes in syndromes revealed a signi®cant correla-
tion between the depressive syndrome and the
positive as well as the negative syndrome (Table 3).
At the symptom level, we found some symptoms of
the positive and negative, but no symptoms of the
extrapyramidal syndrome to be signi®cantly corre-
lated with the depressive syndrome at admission
(Table 4). In detail, there were positive correlation
between the depressive syndrome and the symptoms
`inhibited thinking' and `feeling of loss of feeling',
which were both part of the negative syndrome.
Negative correlations were observed between the
depressive syndrome and the symptoms `system-
atized delusions', `incoherence', `blunted affect' and
`parathymia'.
Acute outcome in depressed and non-depressed schizophrenic
patients
Acute outcome parameters were de®ned as the
presence of depressive, negative and positive
symptoms at discharge, as length of hospital stay
and global social functioning at discharge (see
Table 2). Concerning the length of hospital stay (see
Table 5), the negative and positive symptoms, no
signi®cant differences between the depressed and
non-depressed patients were found, showing that
acute treatment response according to these para-
meters was comparable for both groups. The
initially depressed patients were also signi®cantly
more depressed than the non-depressed group at
discharge. However, the summary score for both
groups of patients was low, indicating that the
depression was not clinically signi®cant. This
interpretation is supported by the results concerning
the global social functioning at discharge (GAS),
which revealed better functioning in the initially
depressed patients at discharge. At admission, both
groups of patients had a comparable degree of
social functioning. To summarize, these results only
slightly support the suggestion of a better acute
outcome for depressed schizophrenic patients
compared to non-depressed schizophrenic patients.
Sociodemographic parameters in depressed and non-depressed
schizophrenic patients
The comparison of sociodemographic characteris-
tics, including marital and occupational status,
between patients with and without a clinically
signi®cant depression revealed the following major
results (see also Table 5): the depressed patients
were signi®cantly older, more frequently married,
less frequently single, less often unemployed and
more frequently had siblings with a history of
psychiatric disorders other than schizophrenia than
the non-depressed patients. Further signi®cant
differences between both groups were not detected.

Table 3. Correlation between the depressive syndrome and the negative, positive and extrapyramidal syndrome at time of admission and their corresponding changes from
admission to discharge (Pearson's correlation index N=155)

Syndromes at time of admission Changes of syndromes

Negative Positive Extrapyramidal Negative Positive Extrapyramidal
syndrome1 syndrome1 syndrome1 syndrome2 syndrome2 syndrome2

Depressive syndrome1 0.002 0.015 x0.052 Depressive syndrome2 0.351 0.313 x0.041
2-Tailed P-value NS NS NS 0.001 <0.001 NS
1 2
Syndromes at time of admission. Changes of syndromes.

156
 Factors of depression in schizophrenic patients

Table 4. Signi®cant correlation between the depressive syndrome and single items phrenic patients, Koreen et al. (11) found that the
of the positive syndrome and the negative syndrome at time of admission (Pearson's
prevalence of depressive symptoms at baseline
correlation index, n=155)
ranged from 75% (patients who reached extracted
Depressive syndrome 2-Tailed P-value Hamilton depression scores of 15 or greater and/or
syndrome criteria (RDC)) to 22% (patients who
Symptoms of the
positive syndrome
meet both criteria). House et al. (18), who
Systematized delusions x0.210 0.009 evaluated the prevalence of depression in 68
Symptoms of the negative syndrome patients experiencing their ®rst episode of schizo-
Inhibited thinking 0.298 <0.001 phrenia diagnosed according to ICD-9, found a
Incoherence x0.227 0.004
Feeling of loss of feeling 0.364 <0.001
baseline prevalence rate of 22% (depression de®ned
Blunted affect x0.166 0.039 by PSE). MoÈller et al. (2, 3) investigated the
Parathymia x0.197 0.014 prevalence of depression in a sample of 81
schizophrenic inpatients (60% ®rst admissions).
They found a prevalence rate of 49% for the
Discussion symptom `depressed mood'. This result is compar-
Depressive symptoms in ®rst admitted patients able to our ®nding, which has shown a prevalence
with schizophrenia are frequent. From a total of rate of 38.5% for `depressed mood' in a much
998 patients, about 40% had a depressed mood at larger sample of patients.
the time of admission; 15.5% ful®lled the criteria Which background factors in¯uence depression
for clinically signi®cant depression. These ®ndings in ®rst admitted schizophrenic patients? In our
are in line with the literature. Prevalence rates for sample of patients, psychosocial stressors or dura-
depression in schizophrenic patients range from tion of symptoms before admission do not seem
7% to 70% (for review see (1)). Burrows and to have a signi®cant in¯uence on the occurrence
Norman (17) reported a modal rate between 25% of depression. Neuroleptic-induced depression does
and 50%. In a ®rst-episode study with schizo- not seem very probable at the time of ®rst admission

Table 5. Comparison of sociodemographic parameters and duration of symptomatology distinguishing between schizophrenic patients with and without clinically relevant
depression

Patients with Patients without

Characteristics depression depression Signi®cance1

Number (% of total) 155 (15.5%) 843 (84.5%)

Age (years, meantSD) 32.90t12.10 30.40t10.43 0.016*
Age at ®rst episode (years, meantSD) 29.33t11.76 26.83t9.89 0.005*
Gender (female/male) 85/70 402/441 NS
Family history of psychiatric disorders
For schizophrenia (n, (%)) 13 (8.4) 75 (8.9) NS
For other psychiatric disorders (n, (%)) 49 (31.6) 188 (22.3) 0.012
Marital status (n (%))
Single 100 (64.5) 624 (86.1) 0.015
Married 39 (25.2) 154 (18.3) 0.046
Divorced or separated 13 (5.9) 50 (8.3) NS
Widowed 3 (1.9) 15 (1.8) NS
Occupational status (n (%))
Employed 79 (51) 399 (47.3) NS
In training programme 23 (14.8) 179 (21.2) NS
Unemployed 3 (1.9) 51 (6.0) 0.037
Housewife 19 (12.3) 65 (7.7) NS
No speci®c information 31 (20) 149 (17.7) NS
Frequency of psychosocial stressors before admission (n (%)) 59 (38.1) 266 (31.6) NS
Duration of symptoms before admission (n (%))
f1 week 16 (10.3) 137 (16.3) NS
>1 week and f1 month 34 (21.9) 195 (23.1) NS
>1 month and f3 month 26 (16.8) 132 (15.7) NS
>3 month and f6 month 24 (15.5) 88 (10.4) NS
>6 month and f1 year 13 (8.4) 71 (8.4) NS
>1 year and f2 years 19 (12.3) 116 (13.8) NS
>2 years and f3 years 9 (5.8) 27 (3.2) NS
>3 years 14 (9.0) 77 (9.1) NS
Duration of hospital stay (days, meantSD)) 56.19t37.04 56.64t42.23 NS*
1
Statistical analyses were performed by using x2 statistics or 2-tailed t-test for independent samples; the latter is indicated by*.

157
Bottlender et al.
but cannot be totally excluded, since medication
data of the patients are not available in our
computerized documentation system. However,
the absence of a signi®cant correlation between
extrapyramidal symptoms and the depressive
syndrome at admission, as well as the observed
decrease of depressive symptoms during the neuro-
leptic treatment period in the hospital, does not
suggest that the detected depression was induced
primarily by the neuroleptic medication. This
interpretation is in line with the conclusion made
by Siris (1), who argued that the evidence drawn
from a review of studies dealing with this topic
weighs against the notion that secondary depression
in schizophrenia could be explained as a neuroleptic
side effect.
The ®ndings which have been reported in the
literature concerning the association between
depressive and negative or positive symptoms are
heterogeneous and depend on various methodolo-
gical conditions. In our study of ®rst admitted
patients who ful®lled the ICD-9 criteria for
schizophrenia, the negative and positive syndrome
did not have a signi®cant in¯uence on the
depressive syndrome at admission in the subgroup
of patients with clinically signi®cant depression.
Comparable results have been reported by Dollfus
et al. (19) for schizophrenic patients according to
the ICD-9 criteria. In this study, however, it was
also shown that the correlation between the
syndromes depends on the criteria which were
applied for diagnosis of schizophrenia. The most
interesting ®nding on this matter was the existence
of signi®cant negative correlation between the
depressive and positive syndrome in patients who
were classi®ed according the DSM-III-R or
Langfeldt criteria for schizophrenia, and the
absence of such a correlation in schizophrenic
patients according to ICD-9. This ®nding high-
lights the restrictions which should be taken into
account when results of different studies dealing
with this topic are compared. Although we have
found no direct correlation between the depressive
and positive or negative syndrome, changes in the
different syndromes (differences in summary scores
between the time of admission and the time of
discharge) were signi®cantly correlated. This
observation may indicate relevant interactions
between the assessed syndromes, but could be
more appropriately explained by an indirect
correlation via treatment effects which are related
to remission of symptoms in all syndromes. Since
several reports in the literature (e.g. (19, 20))
indicate that some positive or negative symptoms
may be of a special relevance for the depressive
symptomatology in schizophrenia, we have ana-
lysed the correlation between single symptoms of
158
the negative and positive syndrome and the
depressive syndrome at admission. This analysis
has shown a positive correlation between the
depressive syndrome and the symptoms `inhibited
thinking' and `feeling of loss of feeling', which
were both part of the negative syndrome. This
result may be due to a symptomatic overlap of the
depressive and negative dimension of schizo-
phrenic psychopathology. The symptom `feeling
of loss of feeling' is assessed in the negative as well
as in the depressive syndrome. The symptom
`inhibited thinking' is not part of the depressive
syndrome of the AMDP but is nevertheless a
typical symptom of depression. Although these
®ndings do not indicate a substantial overlap
between the negative and depressive syndrome, the
®ndings point to the importance of a syndrome
speci®c symptom-selection in assessing both syn-
dromes in schizophrenic patients. Regarding this
point, a limitation of our study may be that the
depressive syndrome of the AMDP in contrast to
the Calgary depression scale (21) has not been
shown to be speci®c of depressive symptoms in
schizophrenia.
As well as the reported positive correlation, we
also found that some symptoms of the negative and
positive syndrome (`systematized delusions', `inco-
herence', `blunted affect' and `parathymia') were
negatively correlated with the depressive syndrome
at the time of admission. The negative correlation
which was found for the symptoms `parathymia'
and `blunted affect' may be explainable by the fact
that patients who ful®l the criteria for these
symptoms are unable to express a depressive
mood. The same may account for patients with
incoherent thinking, whereby these patients may be
unable to communicate a depressive mood ade-
quately, although it may be existent. The latter
interpretation is in line with Knights and Hirsch
(22), who introduced the term `revealed depression',
and argued that although depressed symptoms are
most prevalent in the acute phase of schizophrenia
they tend to go unnoticed or unappreciated because
of ¯orid psychotic symptoms. This interpretation
may also apply for the observed negative correla-
tion between the symptom `systematized delusion'
and the depressive syndrome. To summarize, our
results do not reveal a substantial in¯uence of
extrapyramidal, negative or positive symptoms on
depression in ®rst admitted, clinically depressed
schizophrenic patients.
In this context it could be questioned whether
schizophrenic patients with clinically signi®cant
depression have a genetic background which is
different from that of schizophrenic patients with-
out clinically signi®cant depression. To investigate
this question, we considered the patient's family

history for psychiatric disorders. We found that
the genetic load for schizophrenia (siblings with
schizophrenia) was comparable for the depressed
and non-depressed patients, but the genetic load
for other psychiatric disorders was signi®cantly
higher in the depressed group. As information
about the speci®c nature of the other psychiatric
disorders is not available in our computerized
documentation system, we cannot conclude that
the genetic load for affective disorders is more
prominent in depressed schizophrenic patients than
in those without depression. However, Kendler
and Hays (23) found that schizophrenic patients
with bipolar ®rst-degree relatives were more
depressed during the prodrome. Furthermore,
they found that schizophrenic patients with uni-
polar depressed ®rst-degree relatives had a sig-
ni®cantly higher risk of experiencing depression
following the resolution of a psychotic episode.
Galdi and colleagues (24) found that neuroleptics
have been speci®cally associated with the emer-
gence of depression-like symptomatology in
schizophrenic patients with depressed relatives.
A further important ®nding of our study was the
high prevalence of suicidal tendencies in depressed
schizophrenic patients. Suicidal tendencies were
present in 21.8% of all schizophrenic patients.
Among clinically depressed patients, suicidal
tendencies occurred in 40% compared to 18.5%
in non-depressed patients. Barnes et al. (25) also
reported more suicidal ideation for depressed
compared to non-depressed schizophrenic patients.
Marneros et al. (26) found that 180 (15%) patients
from 1208 ®rst-hospitalized schizophrenic patients
had suicidal tendencies. However, Marneros did
not compare those patients with and without
depressive symptoms. Koreen et al. (11) reported a
rate of 17% for suicidal ideation at baseline.
Without regarding depression and suicidal tenden-
cies, there were only a few further signi®cant
differences between the depressed and non-
depressed patients according to the initially
assessed variables (see Tables 1±3). Differences in
the sociodemographic data were found concerning
age and marital and occupational status, showing
that the depressed patients were older, more
frequently married, less frequently single and
unemployed than the non-depressed patients.
These differences indicate somewhat better pre-
morbid social functioning in depressed schizo-
phrenic patients compared to non-depressed
patients. However, global assessment of function-
ing (GAS) did not show signi®cant differences at
admission. Further, we found no differences for
gender distribution, length of duration of symp-
toms before admission or distribution of the
subtype of schizophrenia. The latter results were
Factors of depression in schizophrenic patients
consistent with those of Koreen et al. (11). An
older age at onset of schizophrenia for depressed
patients was also found by Berrios and Bulbena
(27), but not in the study by Koreen et al. (11).
Roy et al. (28) investigated the prevalence of
depression in chronic schizophrenic out-patients
and found that the depressed patients were more
often living alone (11 depressed vs. four non-
depressed patients, 61% vs. 22%). This result is
contradictory to our ®nding that the depressed
patients were more frequently married and less
frequently single (see Table 3). These differences
may be explained by differences in sample selection
(chronic vs. ®rst admitted patients) and sample
size.
The relevance of depressive symptoms for out-
come in schizophrenia has been discussed contro-
versially in the literature. For the acute outcome,
depressive symptoms may be favourable. In our
study, this suggestion is only slightly supported by
the better GAS score for depressed schizophrenic
patients at discharge. Comparable ®ndings have
been reported by Koreen et al. (11). Depression in
the chronic course of schizophrenia, however, often
appears to be an unfavourable sign and has been
associated with a greater risk for suicide and relapse
(1, 29). The latter question was not addressed in this
study, but will be addressed in a subsequent, as yet
unpublished, work in which we present the data of
a 15-year follow-up study of a subsample of the
patients presented here.
In conclusion, our results give further evidence
that depression in ®rst admitted schizophrenic
patients may represent a distinct psychopatholo-
gical dimension of the acute illness in a subgroup
of patients. The relationship between suicidal
tendencies and depression in schizophrenic patients
highlights the importance of recognizing depressive
symptoms in patients with schizophrenia and
initiating speci®c treatment strategies, not only
for the remission of depression in the acute episode
but also for preventing further depression after
recovery.
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