Depression with psychotic symptoms or “psychotic depression” (PD) is a prevalent, under-diagnosed and under-treated mental disorder, which has received disproportionally little attention by clinicians, researchers and the pharmaceutical industry.

To document potential ambiguity in current treatment guidelines on PD and to determine whether such heterogeneity is reflected in the clinical practice of Danish psychiatrists.

To answer the following questions:

1. Is there consensus regarding first-line treatment of PD among the major treatment guidelines?

2. Do Danish psychiatrists treat PD in accordance with the guidelines?

3. Which antidepressants (AD) and antipsychotics (AP) are first-line choices among psychiatrists?

1. 1. Review and comparison of 10 international guidelines on the treatment of PD with main focus on first-line treatment.

2. 2. Questionnaire based survey on psychiatrists treatment of PD conducted at the annual meeting of the Danish Psychiatric Society.

Treatment guidelines had vastly different opinions on first-line treatment choice: 8/10 suggesting AD+AP combination therapy, 2/10 preferring AD monterapy and 6/10 finding ECT equally appropriate as first-line treatment. the 113 surveyed doctors reflected the same heterogeneity. the preferred first-line treatment choices where AD+AP combination therapy (41.6%), AD monotherapy (31.0%) and ECT (21.2%). the firstline choices regarding ADs and APs were TCA (51.3%) and quetiapine (62.0%) respectively.

There is clear evidence that the treatment of psychotic depression is heterogeneous, as seen in both various international guidelines and the survey of clinical practice. This is most likely due to a weak body of evidence to support clear recommendations in the guidelines.