Review article
Psychomotor retardation in depression: Biological underpinnings, measurement, and treatment

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Abstract

Psychomotor retardation is a long established component of depression that can have significant clinical and therapeutic implications for treatment. Due to its negative impact on overall function in depressed patients, we review its biological correlates, optimal methods of measurement, and relevance in the context of therapeutic interventions. The aim of the paper is to provide a synthesis of the literature on psychomotor retardation in depression with the goal of enhanced awareness for clinicians and researchers. Increased knowledge and understanding of psychomotor retardation in major depressive disorder may lead to further research and better informed diagnosis in regards to psychomotor retardation. Manifestations of psychomotor retardation include slowed speech, decreased movement, and impaired cognitive function. It is common in patients with melancholic depression and those with psychotic features. Biological correlates may include abnormalities in the basal ganglia and dopaminergic pathways. Neurophysiologic tools such as neuroimaging and transcranial magnetic stimulation may play a role in the study of this symptom in the future. At present, there are three objective scales to evaluate psychomotor retardation severity. Studies examining the impact of psychomotor retardation on clinical outcome have found differential results. However, available evidence suggests that depressed patients with psychomotor retardation may respond well to electroconvulsive therapy (ECT). Current literature regarding antidepressants is inconclusive, though tricyclic antidepressants may be considered for treatment of patients with psychomotor retardation. Future work examining this objective aspect of major depressive disorder (MDD) is essential. This could further elucidate the biological underpinnings of depression and optimize its treatment.

Research Highlights

Psychomotor retardation is a major feature of major depressive disorder (MDD). ► Psychomotor retardation can be measured with scales and physiologic measures. ► Psychomotor retardation may predict response to electroconvulsive therapy. ► Psychomotor retardation may have predictive value for response to antidepressants. ► Existing research suggests that this symptom of MDD has biological correlates.

Introduction

Psychomotor retardation has been characterized as a major feature of depression since antiquity. Hippocrates and Aretaeus of Cappadocia both described psychomotor retardation as a characteristic of depression (Sobin and Sackeim, 1997, Whitwell, 1936, Zilboorg, 1944). Darwin also discussed visible psychomotor symptoms and depressed patients who “no longer wish for action but remain motionless and passive, or may occasionally rock themselves to and fro” (Dantchev and Widlocher, 1998, Greden and Carroll, 1981). In the proceeding decades, authors such as Kraepelin expanded on psychomotor retardation, building upon the knowledge of this noteworthy phenomenon by describing how it was more prominent than depressed mood and involved constrained speech, thought, and behavior (Greden and Carroll, 1981, Sobin and Sackeim, 1997).

Presently, psychomotor retardation is regarded as a key aspect of major depressive disorder (MDD) (American Psychiatric Association, 2000, Greden and Carroll, 1981, Widlocher, 1983). In the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSM IV-TR), it is one of the 9 core symptoms identified to diagnose MDD (American Psychiatric Association, 2000). Psychomotor retardation is also a principal symptom of MDD with melancholic features (American Psychiatric Association, 2000, Parker, 2005). Despite its long observed prevalence in MDD, the characterization and clinical significance of psychomotor retardation are poorly understood (Greden and Carroll, 1981, Sobin and Sackeim, 1997). This review will examine the biological correlates, measurement, and treatment implications of psychomotor retardation.

The aim of the paper is to provide a synthesis of the literature on psychomotor retardation in depression with the goal of enhanced awareness for clinicians and researchers. Increased knowledge and understanding of psychomotor retardation in major depressive disorder may lead to further research and better informed diagnosis in regards to psychomotor retardation. To carry out a systematic review, the lead author (JSB) performed independent searches in PubMed (1900–2010) database with the following terms: psychomotor retardation, major depressive disorder, motor, speech, melancholia, antidepressant, electroconvulsive therapy (ECT), and scale. The systematic review included only the articles that mentioned psychomotor retardation and at minimum, one other key search term in the abstract. Reference sections were also reviewed for additional sources. A total of 154 articles (English language literature) were included in this review. These studies were between the dates of 1936–2010, from Australia, Austria, Belgium, Canada, Denmark, France, Germany, Ireland, Italy, Japan, Mexico, Netherlands, New Zealand, Switzerland, United Kingdom, and United States; the methodologies and study designs varied.

Section snippets

Observable characteristics

Psychomotor retardation is unique in regards to depressive symptomatology as it is assessed through direct behavioral observations of speech, facial expression, eye movements, self-touching, posture, and speed and degree of movements (Jones and Pansa, 1979, Parker and Hadzi-Pavlovic, 1996, Sobin and Sackeim, 1997, Widlocher, 1983). Speech has been extensively studied in the context of depression and psychomotor retardation (Greden et al., 1981, Hardy et al., 1984, Sobin and Sackeim, 1997,

Biological correlates of psychomotor retardation in MDD

Previous work has examined the possible pathophysiology of psychomotor changes in mood disorders. It is appealing to consider other neuropsychiatric disorders with psychomotor changes such as schizophrenia, Parkinson's disease and Huntington's disease as these disorders have high incidences of depressive symptomatology. This would also suggest that the basal ganglia play a critical role in psychomotor retardation in mood disorders. The basal ganglia encompass the caudate nucleus, lentiform

Objective measurements of psychomotor retardation

Neuropsychological measures of psychomotor retardation assess its associated cognitive and motor behaviors to provide an objective approach for its quantification (Szabadi et al., 1976). Circadian rhythms and medication are important confounding factors that should be accounted for when measuring psychomotor retardation (Joffe et al., 1987, Moffoot et al., 1994, Parker and Hadzi-Pavlovic, 1996, Sabbe et al., 1997). For example, psychomotor retardation is typically more pronounced in the morning

Psychomotor retardation scales

Increasingly, psychiatrists in research and clinical practice use depression rating scales that assess the severity of depressive symptoms in patients. However, most depression scales have a minimal number of questions that assess psychomotor retardation. For example, the Montgomery–Asberg Depression Rating Scale (MADRS), a scale commonly used depression severity measure in research studies assess “lassitude” but no other items address psychomotor retardation (Fantino and Moore, 2009). The

Predictive value of psychomotor retardation to clinical outcome with antidepressant pharmacotherapy

Pharmacotherapy for depressed patients is guided by treatment algorithms, clinical judgment, and existing evidence from clinical trials. It is the hope that translational genetics and neuroimaging research will one day provide individualized treatment plans. Currently, there is a dearth of scientific evidence to guide individual antidepressant treatment planning (Taylor et al., 2006). Generally, the first line of treatment involves selective serotonin reuptake inhibitors (SSRIs). Atypical

Predictive value of psychomotor retardation to clinical outcome with electroconvulsive therapy

The use of electroconvulsive therapy (ECT) dates back to the 1930s; however, there is still much to learn regarding which subgroups of patients with MDD respond best to the treatment (Buchan et al., 1992, Hickie et al., 1990, Hickie et al., 1996a, Mendels, 1965a, Mendels, 1965b, Mendels, 1965c, Rasmussen, 2003, Weller and Weller, 2000). ECT is typically reserved for patients who do not benefit from other antidepressant treatments, are acutely suicidal or psychotic, or who present with catatonic

Repetitive transcranial magnetic stimulation (rTMS) treatment effect on psychomotor retardation

Repetitive transcranial magnetic stimulation is a treatment option for depression, with increasing use in clinical practice (Schonfeldt-Lecuona et al., 2010). Treatment with rTMS involves using a changing magnetic field to depolarize neurons and trigger action potentials (Ruohonen and Karhu, 2010). In 2008, the FDA cleared the use of rTMS to treat adults with MDD, who have failed at one trial of an antidepressant medication (Ruohonen and Karhu, 2010).

Although currently there is no literature on

Conclusion

The study of psychomotor retardation has significantly broadened the understanding and recognition of this unique symptom far beyond that of Darwin and Kraepelin. Motor symptoms, such as moving and speaking slowly, can now be analyzed quantitatively and studied in further depth. Emerging neuropsychiatric tools may further the understanding of psychomotor aspects of depression (Bajbouj et al., 2006, Loo et al., 2008, Steele et al., 2000). In addition, psychometric assessment scales exist that

Acknowledgements

This publication was supported by Grant Number R25 MH74675 (PI: Graham Emslie) and K23 MH087739 (PI: Shawn McClintock) from the National Institute of Mental Health (NIMH), and Grant Number UL1 RR024982 (PI: Milton Packer) from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH).

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