Inclusion criteria
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1)
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Aged 18-85 years, inclusive
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2)
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Diagnosis: DSM-IV non-bipolar major depression with psychotic features, established through both a clinical interview by a research psychiatrist and the subsequent administration of the SCID-IV by a research associate
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3)
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Score of ≥3 on the delusion severity item of the SADS (‘delusion definitely present’), with or without hallucinations on the SADS hallucination item
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4)
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Score of >2 on any of the three conviction items of the DAS (the participant is certain a belief is true and does not change the belief in response to reality testing by the interviewer);
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5)
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17-item Ham-D score of >21.
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Exclusion criteria
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1)
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Current or lifetime DSM-IV criteria for: schizophrenia, schizoaffective disorder or other psychotic disorder, mental retardation, or meeting DSM-IV criteria for current brief psychotic disorder, body dysmorphic disorder, or obsessive-compulsive disorder
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2)
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Current or lifetime DSM-IV criteria for bipolar affective disorder
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3)
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History of DSM-IV defined substance abuse or dependence, including alcohol, within the last three months
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4)
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DSM-IV defined Alzheimer’s dementia, vascular dementia, or dementia due to other medical conditions, or a history of clinically significant cognitive impairment prior to the index episode of depression, and/or a mean score of ≥4 on the 26-item IQCODE. The IQCODE will be used to screen for clinically significant cognitive decline that began prior to the index episode of PD (a cut score of 4 has been found to have a sensitivity of 84-93% and specificity of 88-94% in screening for dementia in general, psychiatric, and medical populations of older adults
[30,31]
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5)
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Type 1 diabetes mellitus (defined as insulin-dependent diabetes mellitus with onset < 35 years of age and/or diabetes mellitus that has been complicated by a prior documented episode of ketoacidosis)
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6)
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Acute or unstable medical illnesses (e.g., delirium; metastatic cancer; unstable diabetes, decompensated cardiac, hepatic, renal or pulmonary disease; stroke; or myocardial infarction) within the last three months; current abnormal serum free T4; current abnormally low serum vitamin B12 or folic acid level; medical conditions and/or medications for which psychotic or depressive symptoms can be a direct manifestation (e.g. Cushing’s disease, high-dose systemic corticosteroids, L-dopa); neurological disease associated with extrapyramidal signs and symptoms (e.g. Parkinson’s disease); epilepsy, if the person has had one or more grand mal seizures in the past 12 months
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7)
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The need for treatment with any psychotropic medications other than sertraline, olanzapine, or lorazepam; or with an anticonvulsant medication with mood-stabilizing properties (carbamazepine, lamotrigine, valproic acid)
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8)
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Current pregnancy or a plan to become pregnant during the duration of the study in woman of childbearing age; breast-feeding in woman with infants
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9)
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A clearly documented history of being unable to tolerate sertraline and/or olanzapine, including having had an untoward previous reaction to sertraline such as significant bradycardia (heart rate of <50 bpm) or development of the syndrome of inappropriate antidiuretic hormone secretion with a serum sodium of 129 mmol/L or below
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10)
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History of non-response of the index episode of PD to at least a 6-week trial of ≥150 mg/day sertraline combined with ≥ 15 mg/day olanzapine
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11)
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Patients showing ongoing improvement in the index episode of PD with treatment, other than sertraline and olanzapine, initiated prior to the study
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12) |
Sufficiently ill to require immediate ECT (e.g., imminent risk of suicide, refusing to eat or severe malnutrition, catatonic) |