Original Paper / Araştırma DOI: 10.5455/jmood.

20160328052653

Factors Associated with Depression in Patients with

Schizophrenia
Gülcan Balcı1, Gözde Başefe Öter2, Hatice Alkan Akdağ3, Alper Bekki4, Cebrail Kısa5, Erol Göka6

ÖZ: ABS­TRACT:
Şizofreni hastalarında görülen depresyonla Factors associated with depression in
ilişkili faktörler patients with schizophrenia

Amaç: Bu çalışmada, Mental Bozuklukların Tanısal ve
Sayımsal El Kitabı’na (Diagnostic and Statistical Manual
of Mental Disorders -DSM5) göre şizofreni tanısı almış
hastalarda depresyon yaygınlığının saptanması, depres-
yonla ilişkili sosyodemografik faktörlerin belirlenmesi,
şizofrenideki depresyonun pozitif ve negatif belirtileriyle
antipsikotik ilaçların yan etkileri ve içgörü ilişkisinin araştı-
rılması amaçlanmıştır.
Yöntem: Rastgele seçilen 120 şizofreni hastası sosyode-
mografik özellikleri ve elde edilen pozitif-negatif belirtiler,
şizofrenide depresyon, ekstrapiramidal belirtiler ve içgörü
değerlendirme ölçek skorları bakımından incelenmiştir.
Bulgular: Bu çalışmada şizofrenide depresyon görülme
oranı %42.5 bulunmuştur. Şizofrenide görülen depresyo-
nun düşük sosyoekonomik durum, ailede psikoz öyküsü
ve ailede iki uçlu bozukluk öyküsünün varlığı, hastada
intihar girişimi öyküsü ve tedavisiz kalınan süre ile ilişkili
olduğu saptanmıştır. Ayrıca varsanılar ve sanrılar alt ölçeği,
duygulanımda düzleşme, aloji, avolüsyon, apati ve dikkat
Objective: In this study, it is aimed to determine the
prevalence of depression rate, socio-demographic factors
related to depression and to determine the relationship
between depression in schizophrenia with positive and
negative symptoms, insight and antipsychotics drugs’
side effects in patients with a diagnosis of schizophrenia
according to the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5).
Method: Randomly selected 120 schizophrenia patients
are examined regarding socio-demographic characteristics,
obtained positive and negative symptoms, depression
in schizophrenia, extrapyramidal symptoms, and insight
scale scores.
Results: Depression rate in schizophrenia is found as
42.5%. Depression is related to low socioeconomic status,
family history of psychosis and affective disorders, patients’
suicide history and run-in period. Also, hallucinations
and delusions sub-scales, flattening, alogia, apathy and
attention sub-scales, Parkinsonism sub-scale and insight
1
Birecik State Hospital, Psychiatry Clinic,
Şanliurfa-Turkey
2
Sanliurfa Training and Research Hospital,
Department of Psychiatry, Sanliurfa-Turkey
3
Bursa Training and Research Hospital,
Department of Psychiatry, Bursa-Turkey
4
Anadolu University, Faculty of Science,
Department of Statistics, Eskisehir-Turkey
5
Diskapi Yildirim Beyazit Training and
Research Hospital, Department of Psychiatry,
Ankara-Turkey
6
Ankara Numune Training and Research
Hospital, Department of Psychiatry,
Ankara-Turkey
Ya­zış­ma Ad­re­si / Add­ress rep­rint re­qu­ests to:
Alper Bekki,
Anadolu University, Faculty of Science,
Department of Statistics, Eskisehir-Turkey
Elekt­ro­nik pos­ta ad­re­si / E-ma­il add­ress:
abekki@anadolu.edu.tr

alt ölçekleri, parkinsonizm alt ölçeği ve içgörü düzeyi ile
depresyonun doğrudan ilişkili olduğu da belirlenmiştir.
Sonuç: İlişkili sosyodemografik faktörlerin incelenmesi
depresyon belirlenmesinde yardımcıdır ve depresyon,
şizofreninin tüm evrelerine eşlik edebilir. Sonuç olarak
depresyon şizofreninin temel göstergelerinden biri olabilir.
Anahtar kelimeler: şizofreni, depresyon, depresif belirtiler
Journal of Mood Disorders (JMOOD) 2016;6(2):54-62
levels are found directly related to depression. Geliş ta­ri­hi / Date of received:
19 Ocak 2016 / January 19, 2016
Conclusions: Examining related sociodemographic factors
can aid in determining depression and depression may Ka­bul ta­ri­hi / Da­te of ac­cep­tan­ce:
28 Mart 2016 / March 28, 2016
accompany all the phases of schizophrenia. Therefore, it
can be one of the basic indications of schizophrenia. Bağıntı beyanı:
G.B., G.B.Ö., H.A.A., A.B., C.K., E.G.: Yazarlar
bu makale ile ilgili olarak herhangi bir çıkar
Keywords: schizophrenia, depression, depressive çatışması bildirmemişlerdir.
symptoms Declaration of interest:
G.B., G.B.Ö., H.A.A., A.B., C.K., E.G.: The
authors reported no conflict of interest
Journal of Mood Disorders (JMOOD) 2016;6(2):54-62 related to this article.

INTRODUCTION It is still an ongoing argument subject whether depressive

Depressive symptoms in patients with schizophrenia are
reported since the day that syndrome has been defined. Siris
found the rate of depression prevalence changing from %7 up
to %70 and stated that depressive symptoms may be observed
in all periods of schizophrenia including the early periods (1).
symptoms occur as a reaction to the disease in the clinic
picture of schizophrenia, or it is a part of a psychotic period.
The relationship between schizophrenia and depressive
symptoms cannot be completely found out because the
difference between affective and psychotic disorder is not so
far from each other regarding etiology, clinic, and treatment.

54 Journal of Mood Disorders Volume: 6, Number: 2, 2016 - www.jmood.org

 G. Balcı, G. Başefe-Öter, H. Alkan-Akdağ, A. Bekki, C. Kısa5, E. Göka
Many different opinions about the time and the progress
of the depressive symptoms seen in schizophrenia are
brought forward. For instance, depressive symptoms are
seen in the active phase of schizophrenia and may be
directly related to positive symptoms, they occur because of
extrapyramidal side effects caused by antipsychotic drugs,
they may occur with insight towards the disease acquired
after the allayment of disease symptoms and due to several
overlapping characteristics with negative symptoms can be
confusing and this may cause failure for the diagnosis of
depression.
The occurrence of depression accompanying
schizophrenia with different reasons and in different
periods during the disease complicates the differential
diagnosis and makes the administration of effective
treatment according to the source of depressive symptoms.
It has been stated that the addition of depression to the
clinic picture of schizophrenia patients affects the prognosis
of the disease quite adversely with increased risk of relapse,
increase of hospitalization frequency and its duration, low
social functioning, disorder in cognitive competence, weak
response to pharmacological treatment, substance abuse
and increasing rates of suicide attempts.
This study is planned to determine the frequency of
schizophrenia in the patients applying for our clinically
observed by us, the socio-demographic variables which will
make the determination of depression easier and finding in
which phase of schizophrenia depression occurs. Therefore,
we can give an actual answer to hypothesis whether
depression is one of the main symptoms of schizophrenia
or not. Original researches conducted in the last 5-10 years
in this field are quite a few. For this reason, this research is
important regarding reawakening the clinical importance
of the depression seen in schizophrenia.
METHODS
Participants
120 patients who consulted to Ankara Numune
Education and Research Hospital, between the age of 18-65,
diagnosed with schizophrenia according to DSM 5
diagnostic criteria, had not taken electroconvulsive
treatment (ECT) in last 1 year, not identified with serious
physical and neurologic disease, had not used alcohol and/
or psychoactive substance, not identified with mental
Journal of Mood Disorders Volume: 6, Number: 2, 2016 - www.jmood.org
retardation and another axis I diagnosis except depression
are randomly incorporated into this study. Patients with the
diagnosis of schizoaffective disorder are excluded because
of affective symptoms in diagnosis criteria. The study is
planned as prospective.
Measures
In the study positive and negative symptoms are
measured with “Scale for the Assessment of Positive
Symptoms (SAPS) and Scale for the Assessment of Negative
Symptoms (SANS)” developed by Andreasen (1990), proved
its reliability and validity for Turkish. SAPS consists of 4
subscales evaluated by the clinician, and the sub-scales
involve hallucinations, delusions, unusual/bizarre behavior
and positive formal thought disorder. SANS consists of 5
sub-scales involving blunted affect, alogia, avolition-
apathy, anhedonia / antisociality and attention deficit.
Calgary Depression Scale for Schizophrenia (CDSS)
assesses the schizophrenia patients for depression and
involves total nine subjects: depressive mood, hopelessness,
insignificancy senses, resentment senses related with
guiltiness, pathological guilt, morning depression, early
wakening, self-destruction, and depression observed.
Extrapyramidal Symptom Rating Scale (ESRS) applied
for the reason that the patients used antipsychotic. It
consists four subscales involving dystonia, dyskinesia,
Parkinsonism and akathisia.
Schedule for Assessing Three Components of Insight
(SATCI) consists of 8 questions; it is evaluated by the
clinician, assessing insight quantitatively based on three
components as compliance to treatment, awareness of the
disease, correct recognition of psychotic experiences.
Patient Socio-demographic Data Form: 20 different
descriptive variables have been searched. Information
related to age, sex, marital status, educational status, period
of education, people living with, number of siblings, the
place lived in, work condition, monthly income of the
household, duration of the disease, the run-in period,
period of regular use of antipsychotic, type of antipsychotic
used, the number of hospitalization, polyclinic control
condition, family history of psychotic disorders, family
history of affective disorders, family suicidal history,
patient’s suicidal history have been learnt through this
form. The form was carried out by the interviewer.
55
 Factors associated with depression in patients with schizophrenia

Statistical Analysis Ethical Provisions

As Calgary Depression Scale for Schizophrenia cutoff
score was taken 12, the ones scored 12 or above were
grouped as “depression (+)”, the ones scored below 12 were
grouped as “depression (-)”. Also the “depression (+) group”
was diagnosed with depression clinically. The relationship
between each of the socio-demographic attributes of
patients and these depression groups are investigated
separately using Pearson chi-square test statistics.
Spearman rank correlation is calculated to determine the
correlation degree and direction for variables statistically
significant in Chi-square test results. According to the
depression groups, whether there is a difference between
average scores of the SAPS, SANS, ESRS, SATCI and their
sub-scales or not is investigated by Student-t test. To find
out which of the sub-scales are more effective regarding
determining depression in schizophrenia is performed by
regression analysis.
Statistical procedures were implemented with the IBM
SPSS Statistics 21 software. The significance level was taken
as α=0.05 for all evaluations.
Required approval for research was taken from Ankara
Numune Education and Research Hospital Ethics
Committee.
RESULTS
Demographic and Medication Characteristics of
Participants
55 female (45.8%) and 65 male (54.2%) as total 120
patients diagnosed with schizophrenia according to DSM-V-
TR were incorporated into the study. The ages of the group
of patients are between 19 and 62, and the average age of the
patients is 35. 30.8% of the patients is married, 50.8% is
single, and 18.4% is widow or divorced. As for educational
status, it was learned that 5.8% of them is uneducated, 45.8%
is a graduate of the primary school, 34.2% is a graduate of
high school, and 14.2% is a graduate of higher education.
While the rate of the ones living in the city is 70.8%; 29.2% of
them lives in the villages. While the rate of the working ones
is 31.7%; 68.3% of them do not work.

Tab­le 1: The relationship between monthly incomes of the household, family history of psychosis, family history of affective
disorders, patient’s suicidal history, run-in period and depression groups
Calgary Depression Scale for Schizophrenia
Calgary lower than Calgary 12 and
12: depression (-) above: depression (+)
n=69 % n=51 % χ2 df p Rs p

The Amount of Monthly Income

of the household 21.245 3 0.000* -0.405 0.000*
0-500 tl 5 27.8 13 72.2
500-1000 tl 26 46.4 30 53.6
1000-1500 tl 26 83.9 5 16.1
1500 tl and above 12 80.0 3 20.0
Family History of Psychosis 7.266 1 0.007* +0.246 0.007*
Yes 48 67.6 23 32.4
No 21 42.9 28 57.1
Family History of Affective Disorder 23.487 1 0.000* +0.442 0.000*
Yes 64 69.9 28 30.4
No 5 17.9 23 82.1
Patient’s Suicidal History
and/or Suicide Thought 15.786 1 0.000* +0.363 0.000*
Yes 62 67.4 30 32.6
No 7 25.0 21 75.0
Run-in Period (month) 16.043 4 0.007* +0.343 0.000*
0-6 months 28 80.0 7 20.0
7-12 months 15 57.7 11 42.3
13-36 months 18 56.3 14 43.8
37-60 months 3 25.0 9 75.0
60 months and above 5 33.3 10 66.7
*statistically significant.

56 Journal of Mood Disorders Volume: 6, Number: 2, 2016 - www.jmood.org

 G. Balcı, G. Başefe-Öter, H. Alkan-Akdağ, A. Bekki, C. Kısa5, E. Göka

As for the average duration of disease, 24.0% of them
had 7-12 months, 20.8% had 1-3 years, 27.5% had between
3-5 years and 27.5% had five years or above.
12.5% of patients was using typical antipsychotic, 83.3%
atypical antipsychotic and 4.2% of them was using typical
and atypical antipsychotics combination treatment.
Relationship between Depression Groups and
Socio-demographic Variables
In our study, depression rate in schizophrenia patients
is found to be 42.5%. A statistically significant relationship
between depression groups and sex, patient’s age, marital
status, educational status, period of education, work
condition, place lived in, people living with, the number of
siblings, antipsychotic used, period of regular use of
antipsychotic, the number of hospitalization, polyclinic
control condition, duration of the disease and family
suicidal history respectively has not been identified.
However, according to the results of chi-square tests,
there is a statistically significant relationship between
depression groups and the variables interested in the
investigation namely monthly income of the household, the
family history of psychosis, the family history of affective
disorders, patient’s suicidal history and the run-in period.
The test statistics and their probability values are shown in
Table 1. Additionally, Table 1 includes the information
about Spearman’s Rank Correlation investigations between
the variables. Again as it can be seen from the Table 1, there
is a statistically significant relationship between the
variables studied for Chi-Square analysis. Further, using the
Spearman’s Rank Correlation coefficient the following
results can be said. There is a moderate negative relationship
between Monthly Income of the Household and Depression
Groups (Rs= -0.405 with p= 0.000). There is a weak positive
correlation between Family History of Psychosis and
Depression Groups (Rs= +0.246 with p= 0.007). There is a
moderate positive correlation between Family History of
Affective Disorders and Depression Groups (Rs= +0.442
with p= 0.000). There is a moderate positive correlation
between Patient’s Suicidal History and Depression Groups
(Rs= +0.363 with p= 0.000). There is a moderate positive
correlation between Run-in Period and Depression Groups
(Rs= +0.343 with p= 0.000).
Comparison of averages of the SAPS, SANS, ESRS,
SATCI and their subscales scores according to
Calgary depression groups
According to depression groups, averages of all scale
scores are compared with two independent sample t-tests.
Descriptive statistics and test results of these scales are
shown in Table 2. According to the test results, probability
values which we had statistically significant averages scores
scales are marked with an asterisk.
The aim of this comparison is to investigate if there is a

Tab­le 2: Comparison of average scores of all scales according to Calgary depression groups
Calgary lower Calgary 12 and
than 12: depression (-) above: depression (+)
N=69 N=51 p
SAPS Score 24.25±20.159 32.55±22.479 0.036*
Hallucinations Total Score (SAPS sub-scale) 3.81±5.571 6.45±7.882 0.044*
Delusions Total Score (SAPS sub-scale) 10.86±7.781 15.98±8.874 0.001*
Unusual (bizarre) Behaviour Score (SAPS sub-scale) 3.35±4.094 3.51±4.061 0.830
Positive Formal Thought Disorder (SAPS sub-scale) 6.25±7.459 6.69±6.398 0.735
SANS Score 32.30±18.669 65.27±17.537 0.000*
Affective Flattening and Blunted Affect Score (SANS sub-scale) 8.45±6.404 18.84±6.670 0.000*
Alogia Score (SANS sub-scale) 4.36±4.472 10.39±4.850 0.000*
Avolution-Apathy/Weakness of will-Apathy Score (SANS sub-scale) 5.94±3.391 10.88±3.793 0.000*
Anhedonia-Antisociality Score (SANS sub-scale) 11.64±4.863 19.57±3.551 0.000*
Attention Deficit Score (SANS sub-scale) 1.77±2.745 5.88±2.732 0.000*
ESRS Score 6.12±8.220 9.10±8.909 0.060
Parkinsonism Score (ESRS sub-scale) 4.29±4.941 6.35±5.090 0.027*
Dystonia Score (ESRS sub-scale) 0.55±1.399 0.67±1.479 0.662
Akathisia Score (ESRS sub-scale) 1.04±2.470 1.63±3.538 0.289
Dyskinezia Score (ESRS sub-scale) 0.23±0.926 0.45±1.346 0.320
SATCI Score 6.80±6.496 12.16±5.312 0.000*
*statistically significant.

Journal of Mood Disorders Volume: 6, Number: 2, 2016 - www.jmood.org 57

 Factors associated with depression in patients with schizophrenia

Tab­le 3: The regression analysis table of SANS, SAPS, ESRS, SATCI versus their sub-scales for the patients with schizophrenia and
depression

Model Unstandardized Standardized

Coefficients Coefficients t Sig.
B Std. Error Beta
Hallucinations Total Score (SAPS sub-scale) 0.089 0.025 0.089 3.529 0.001*
Delusions Total Score (SAPS sub-scale) 0.197 0.024 0.197 8.287 0.000*
Affective Flattening and Blunted Affect Score (SANS sub-scale) 0.248 0.033 0.248 7.478 0.000*
Avolution-Apathy/Weakness of will-Apathy Score (SANS sub-scale) 0.104 0.031 0.104 3.368 0.001*
Anhedonia-Antisociality Score (SANS sub-scale) 0.205 0.029 0.205 7.169 0.000*
Attention Score (SANS sub-scale) 0.203 0.029 0.203 7.053 0.000*
Parkinsonism Score (ESRS sub-scale) 0.207 0.023 0.207 8.895 0.000*
Akathisia Score (ESRS sub-scale) 0.100 0.022 0.100 4.526 0.000*
*statistically significant.

statistically significant difference between averages of all
scale scores according to the depression groups.
According to two independent sampling t-test results
are given in Table 2, there is a statistically significant
difference between the average scores of SAPS,
hallucinations, and delusions, SANS, affective flattening
and blunted affect, alogia, avolition-apathy, anhedonia-
antisocially, attention deficit, parkinsonism and insight
assessment scales of the Calgary depression groups.
Relation of Calgary Depression Scale for
Schizophrenia with SAPS, SANS, ESRS and SATCI
(Regression and Correlation Analysis)
SAPS, SANS, ESRS and CDSS main scales are merged
into one factor by applying factor analysis. Obtained factor
is taken as the dependent variable, and standardized sub-
scales are taken as independent variables for regression
analysis. The purpose of this analysis is to find out which of
the sub-scales are more effective regarding determining
depression in schizophrenia. For this purpose, all
independent variables are included in the model initially,
and final regression model is obtained by using the
backward elimination approach.
In the model independent variables explain %96,9
(R2=0,966) of dependent variable. Reliability of the model is
tested with the variance analysis, and the model is found
statistically significant with F8,112 =400,994 and p=0.000.
Independent variables used to explain the dependent
variable and that are attained through backward elimination
approach, can be seen in the column B. When tested separately,
coefficients of all these independent variables are found to be
statistically significant and can be seen in column “sig”.
In the final model, Hallucinations and Delusions sub-
scales of SAPS, Affective Flattening and Blunted Affect,
Avolition-Apathy, Anhedonia-Antisociality and Attention
Score sub-scales of SANS and Parkinsonism and Akathisia
sub-scales of ESRS are included in the regression model,
and the rest sub-scales are excluded.
DISCUSSION
In our study, depression rate in schizophrenia was
found to be %42,5, and this result is compatible with the
World Health Organization data to show the prevalence of
depression in schizophrenia to be %19-81 (2). Many reasons
such as active psychotic symptoms veiling depression,
overlapping properties of depression and negative
symptoms, side effects of drugs causing depression or
having depressive symptomatology may have caused this.
As a result, it is seen that the depressive symptoms found in
every phase of schizophrenia are responsible for the
variability of prevalence rates.
Our study also shows that family history of affective
disorders or psychosis, as well as existence patient’s suicidal
history, increases the rate of depression. Our results are
compatible with the research findings of Bottlender et al.
showing depressive patients have a higher suicidal tendency
and a family psychiatric history (3). Depressive patients
having a family history of affective disorders can be
explained with the genetic transition of depression. This
situation shows that depression in schizophrenia is not only
a reaction to having psychotic attacks or a part of healing
process. Findings seem to be compatible with the model to
show that the family history or psychosis had an expression

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 G. Balcı, G. Başefe-Öter, H. Alkan-Akdağ, A. Bekki, C. Kısa5, E. Göka
increasing effect on depressive symptoms in schizophrenia.
Correlation of a family history of psychosis and depressive
symptoms of the patient strongly support the opinion of
depression being one of the core symptoms of
schizophrenia. Increased suicidal tendencies in
schizophrenia and depression are shown in many studies
and our research results also support it.
Our study also shows that the lower the monthly income
of the household is, the higher the depression rate gets. Our
result is compatible with Bottlender et al.’s information on
depression in schizophrenia being correlated to lower
socio-economical level (4).
In our study, as the run-in period increases, the rate of
depression has also increased. Depression with
schizophrenia is also shown to be related to more attacks,
hospitalization frequency, and deterioration of psychosocial
functioning and bad response to the treatment (5). Bad
response to the treatment and a long run-in period also
increase the development of depression and intensify it,
resulting in higher risk of suicide, exacerbation of negative
symptoms, and deterioration of cognitive functioning
increased relapses and an overall bad effect on the course of
the disease. For these important reasons, depression must
be taken seriously and treated.
Many studies show that depressive symptoms are a part
of the natural course of schizophrenia, are most seen during
the acute period and decrease during the remission of the
disease (6). It is stated that especially in depression seen
during acute psychotic period, delusions of hopelessness
and self-accusation are more dominant, depressive
symptoms’ severity is correlated to psychotic symptoms,
with allayment of psychotic symptoms the severity of
depressive symptoms also regress and this is interpreted as
“depressive symptoms being a core symptom of acute
model”. It is also stated that in some cases depressive
syndromes are an integral part of patient’s psychotic life
and carry out a lifetime (7). Similarly, Zisook et al.’s study
show that depressive symptoms are related to positive
symptoms; but age, sex, negative symptoms, extrapyramidal
symptoms and antipsychotic doses are not related and this
situation causes to think that one of the core compounds of
the disorder can cause depression through psychotic
symptoms (8). There are also others to show that depressive
symptoms are related to positive symptoms such as hostility
and skepticism (6). Regression and correlation analyzes
carried out in our study; SAPS overall score shows that
Journal of Mood Disorders Volume: 6, Number: 2, 2016 - www.jmood.org
hallucination and delusions sub-scales are related to
depression in schizophrenia. Especially, the high scores of
delusions and hallucinations sub-scales support that as
shown in the studies above, depression, which comes along
with psychotic symptoms in the active psychotic episode, is
one of the core symptoms of schizophrenia.
Relation of depressive symptoms and negative
symptoms of schizophrenia has become the topic of many
studies, and they all have different results. It is not clear
whether the negative symptoms in schizophrenia are
separate from depressive symptoms or are existent in
depressive symptoms. Most researchers agree that
depressive symptoms in schizophrenia can be mistaken for
negative symptoms. The reason is, some symptoms of
schizophrenia and depression overlap. The decrease in
motor activity, apathy, sleep disorder, anorexia,
concentration disorder, attention deficit and anhedonia are
symptoms that can be seen in both groups. Symptoms such
as grieving affect and depressive cognitive compound are
related to depression and identifying them makes it easier
to differentiate.
There are also studies to show that negative symptoms
are independent of depression. Kullhara et al. uphold that
vegetative symptoms such as psychomotor retardation,
energy loss, weight loss, libido loss and cognitive
compounds of depression such as depressive mood,
suicidal thoughts, self-accusation, hopelessness, a decrease
of self-respect are not significantly related to the negative
symptoms. They claim that although negative and
depressive symptoms are similar in looks and observed
behaviors, they are rooted from entirely different processes
(9). When patients with and without insufficiency symptoms
were compared, the first group had lower depression scores
(10). Accordingly, it is claimed that mood shifts can be the
primary symptom of the type of psychosis and negative
symptoms are a different aspect of schizophrenia.
Along with those who claim there is no correlation
between negative symptoms and depression, there are also
those to say there is a small correlation. In the study of Sax
et al. it is stated that symptoms of apathy and anhedonia are
correlated to depressive symptoms whereas positive
symptoms are related to the severity of depression (11). In
the research carried out by Aydemir et al. with the purpose
of finding the difference between schizophrenia patients
with or without depression regarding symptoms, the results
show that negative symptom of blunted affect overlaps
59
 Factors associated with depression in patients with schizophrenia
significantly with apathy and attention deficit (12).
In our research; overall SANS score and score of all sub-
scales are higher in the group with depression in
schizophrenia when compared to the group without. In the
regression and correlation analyzes, SANS and sub-scales
are related to depression in schizophrenia. The results are
compatible with studies to have results of correlation
between depression and negative symptoms of
schizophrenia. Patients, independent from periodical
properties of schizophrenia such as acute-remission, to be
chosen from any period of schizophrenia, all of them taking
antipsychotic treatment and the low number of sampling
are limitations of our study. The mutuality of negative
symptoms such as blunted affect, alogia, avolition-apathy,
anhedonia and attention deficit and symptoms that are
major depressive episode scales are clear. Schizophrenia
patient with the hardship of expressing his/her emotions to
have blunted affect can easily be interpreted as depressive
mood. Similarly, symptoms such as psychomotor
retardation, short responses during the interview,
anhedonia, attention, and concentration deficit can be
mistaken for negative symptoms. These two symptom
groups that are similar in style but different in content are
found to be statistically related in our study. Depressive and
negative symptoms being hard to differentiate in the
clinical case, antipsychotic side effects making this
differentiation even more complicated, our study being
compromised of randomly selected patients and the patient
population not being grouped accordingly with their period
of the disease decrease the liability of the result of our
research.
Antipsychotic drugs both in short and long term use,
cause many side effects to affect long-term well-being
significantly and some to affect course and outcome.
Although there are no certain data, it is emphasized that
antipsychotics cause anhedonia and possibly depression
through dopamine blockage. Restlessness, dysphoria and
sometimes anhedonia may come up during drug use. This
table is accompanied by slowness of movements, a decrease
of spontaneity and other extrapyramidal system symptoms.
The research of Möller HJ et al. to support this view,
states that in 280 schizophrenia patients without
depression, in the beginning, depression development rate
was 41.0% after antipsychotic treatment started (13). In the
research of Baynes et al. in 13.3% of schizophrenia patients’
depression is existent and there is a significant relation
60
between depression and akathisia (6).
Akathisia caused by antipsychotic drugs can easily be
mistaken for depression and can be a situation related to
suicidal thoughts and behaviors. Akathisia with motor
restlessness can easily be differentiated from depression
with clinical examination whereas akathisia without motor
restlessness and with dysphoria is harder to differentiate
from depression.
Eren et al.’s study shows that in patients with EPS
symptoms, that are objectively determined through clinical
examination have a weaker relation to depressive
symptoms; whereas EPS that the doctor cannot objectively
determine but the patient can subjectively feel (akathisia,
akinesia without motor restlessness but dysphoria) have a
stronger relation to depressive symptoms and this situation
has caused false diagnosis of depression (14).
On the contrary, there are also researches to state that
antipsychotic drug-induced depression is controversial.
Siris et al. could not find a parallel relation between the
dose of fluphenazine decanoate used for maintenance
treatment of schizophrenic and schizoaffective patients
and plasma levels and depression severity of the patients.
The claim of a probable neuroleptic side effect is not valid
because of patients on the basis of syndromal depressive
symptoms and non-responsive antiparkinsonian treatment
(15). Alfredsson et al. have also concluded with their study
there is no relation between depressive symptoms of
schizophrenia patients and neuroleptic dose, use of
administration, plasma and BOS levels (16). There are also
studies to show when patients with and without
antipsychotic treatment were compared; there were no
significant differences regarding depression incidence (17).
Today the view of antipsychotic drugs inducing
depression or tendency in schizophrenia patients is still
controversial.
In our study; the results of examination of ESRS mean
scores in groups with and without depression, there was a
statistically significant difference between Parkinsonism
scores of each two groups. Other sub-scales, dystonia,
akathisia and dyskinesia overall ESRS scores did not have
significant differences. In the regression analysis,
Parkinsonism and akathisia are effective in identifying
depression.
Significance in Parkinsonism sub-scale is a sign for
other extrapyramidal side effects such as clinically identified
akinesia, bradykinesia, rigidity, and tremor. Results showing
Journal of Mood Disorders Volume: 6, Number: 2, 2016 - www.jmood.org
 G. Balcı, G. Başefe-Öter, H. Alkan-Akdağ, A. Bekki, C. Kısa5, E. Göka
Parkinsonism and akathisia to be related with depression
seem to be compatible with the view of secondarily
developing depression to antipsychotic treatment.
However, to attain clear results on the topic, there is a need
for examining the relation of antipsychotic type and dose to
depressive symptoms. In our study, there was no significant
relation between antipsychotic type and depression
symptoms, but the relation of depression and the
antipsychotic dose was not examined. Finally; patients
taking antipsychotic treatment at the beginning of our
research and the population not belonging to a specific
phase of the disease (acute or chronic) require interpretation
with many variables and decrease the liability of the results.
On the other hand, it should not be neglected that existence
of akathisia in patients causes false positive depression
diagnosis.
Insight deficit is one of the most common symptoms of
psychotic disorders, especially schizophrenia. A majority of
schizophrenia patients have no awareness of their disease,
symptoms or their need of treatment. Insight level is
affected by the severity of clinical symptoms of
schizophrenia. Along with studies to show that only the
severity of positive symptoms has a linear relationship with
insight level, there are also studies to show the linear
relationship between insight levels and both positive and
negative symptoms (18). Among positive symptoms,
hallucinations and delusions are related to low levels of
insight. There are also scientific publications to research
the relation of insight levels to depressive mood as well as
positive and negative symptoms in the literature. Evren et
al., in their study on the relation of depression to positive
and negative symptoms and insight in patients at acute and
stable phases, have stated that in the stable phase of the
disease high levels of insight is related to high scores of
depression. During the acute phase, negative, positive
symptoms and general psychopathology were identified
and during the stable phase, insight was identified as the
predictors of depressive symptoms (19).
In our study; after examining the relation of groups with
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Journal of Mood Disorders Volume: 6, Number: 2, 2016 - www.jmood.org
scores lower than 12(without depression) and higher than
12(with depression) according to Calgary mean scores of
schedule for assessing insight, a statistically significant
difference was identified between two groups. The group
with depression along with schizophrenia had higher
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Our result of schizophrenia patients with high insight levels
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With this study; we had the results that schizophrenia
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Even though our study sheds light on the relation of
schizophrenia and depression, there is a need for studies
with bigger sampling.
 
Acknowledgments: We thank Mr. Gürkan, Miss Yıldırır,
Mr. Türkkan, Mr. Yirur, Mrs. Tıkır, Mr. Asan and Mr. Çağlar
who kindly provided the data necessary for our analysis.
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