A Cochrane review [Abstract] 1 included 12 RCTs with a total of 929 participants with psychotic depression. In 9 trials inpatients were included. The treatments used were antidepressant vs. placebo (one trial), antipsychotic vs. placebo (2 trials), antidepressant vs. antidepressant (5 trials), antidepressant vs. antipsychotic (one trial), antidepressant plus antipsychotic vs. placebo (2 trials), antidepressant plus antipsychotic vs. placebo plus antidepressant (4 trials) and antidepressant plus antipsychotic vs. placebo plus antipsychotic (3 trials). There were more than one comparisons in some trials. Only a few different antidepressants and antipsychotics were used, the treatment times ranged between 4 and 16 weeks. The main outcome was reduction of severity (response) of depression, not of psychosis. There was no evidence for the efficacy of monotherapy with an antidepressant or an antipsychotic. However, evidence suggests that the combination of an antidepressant plus an antipsychotic is more effective than antidepressant alone (RR 1.83, 95% CI 1.40 to 2.38; 3 RCTs, n=157), more effective than antipsychotic alone (RR 1.83, 95% CI 1.40 to 2.38; 4 RCTs, n=447) and more effective than placebo (RR 1.86, 95% CI 1.23 to 2.82; 2 RCTs, n=148).
Comment: The quality of evidence is downgraded by study quality (drop out rate up to 45%), inconsistency (heterogeneity in treatments) and by indirectness (differences in studied treatments and outcome, short follow-up time).
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