Psychotic depression, also known as major depressive disorder with psychotic features, is a serious condition that requires immediate treatment and close monitoring by a medical or mental health professional.
Major depressive disorder is a common mental disorder that can negatively affect many areas of someone’s life. It impacts mood and behavior as well as various physical functions, including appetite and sleep. People with major depression often lose interest in activities they once enjoyed and have trouble performing everyday activities. Occasionally, they may even feel as if life isn’t worth living.
It’s estimated that about 20 percent of people with major depression also have symptoms of psychosis. This combination is sometimes referred to as psychotic depression. In psychiatry, however, the more technical term is major depressive disorder with psychotic features. The condition causes people to see, hear, or believe things that aren’t real.
There are two different types of major depressive disorder with psychotic features. In both, delusions and hallucinations are present, but the affected person may experience major depressive disorder with mood-congruent psychotic features or with mood-incongruent psychotic features.
Major depressive disorder with mood-congruent psychotic features means that the content of the hallucinations and delusions is consistent with typical depressive themes. These may include feelings of personal inadequacy, guilt, or worthlessness. Major depressive disorder with mood-incongruent psychotic features means that the content of the hallucinations and delusions don’t involve typical depressive themes. Some people may also experience a combination of both mood-congruent and mood-incongruent themes in their delusions and hallucinations.
The symptoms of either type are particularly dangerous, as the delusions and hallucinations can be frightening and can increase the risk of suicide. Prompt diagnosis and treatment is critical to preventing someone from hurting themselves or others.
People with psychotic depression have symptoms of major depression along with psychosis.
The symptoms of major depression include:
- difficulty concentrating
- feelings of hopelessness or helplessness
- feelings of worthlessness or self-hate
- social isolation
- loss of interest in activities once found pleasurable
- sleeping too little or too much
- changes in appetite
- sudden weight loss or weight gain
- talks or threats of suicide
Psychosis is characterized by a loss of contact with reality. The symptoms of psychosis include delusions, or false beliefs and false perceptions, and hallucinations, or seeing and hearing things that aren’t present.
Some people develop false beliefs about their own health, such as believing that they have cancer when they really don't. Others hear voices criticizing them, saying things such as "you're not good enough" or "you don't deserve to live."
These delusions and hallucinations seem real to the person who is experiencing them. At times, they can cause someone to become so panicked that they hurt themselves or others. This is why it’s critical for someone with psychotic depression to seek help as soon as possible.
The exact cause of psychotic depression isn’t known. However, people with a family or personal history of mental disorders are more likely to develop psychotic depression. The condition may occur either on its own or along with another psychiatric condition.
Researchers also believe that a combination of genes and stress can affect the production of certain chemicals in the brain, contributing to the development of psychotic depression. The mental disorder may also be triggered by changes in the balance of hormones in the body.
Psychotic depression is a serious condition that may lead a person to harm themselves or others. A person experiencing psychotic symptoms or a caregiver who witnesses psychotic episodes should contact a mental health professional immediately.
The first thing they will do when diagnosing psychotic depression is perform a physical examination and ask questions about the person's symptoms and medical history. They’ll also likely perform blood and urine tests to rule out other possible medical conditions. If the person has a family history of bipolar disorder, they may screen for manic or hypomanic episodes as well. Such an assessment doesn't necessarily confirm or discount the possibility of bipolar disorder, but it may help them avoid a misdiagnosis.
They may suspect psychotic depression if the person is experiencing symptoms of major depression and psychosis. However, it can be difficult for primary care providers to make a definitive diagnosis. The symptoms of psychosis may not be noticeable, and people don’t always report that they’re experiencing delusions or hallucinations. In these cases, referral to a psychiatrist is indicated.
To be diagnosed with major depression, a person must have a depressive episode that lasts two weeks or longer. They must also have five or more of the following symptoms:
- agitation or slow motor function
- changes in appetite or weight
- depressed mood
- difficulty concentrating
- feelings of guilt
- sleeping too little or sleeping too much
- a lack of interest or pleasure in most activities
- low energy levels
- thoughts of death or suicide
To be diagnosed with psychotic depression, a person must show these symptoms of major depression as well as symptoms of psychosis, such as delusions and hallucinations.
There are currently no FDA-approved treatments specifically for psychotic depression. However, the condition may be treated with a combination of antidepressant and antipsychotic medications or with electroconvulsive therapy (ECT). As with any other mental disorder, people and their families should discuss all treatment options with their healthcare provider or mental health professional.
Most mental health professionals will prescribe a combination of antidepressants and antipsychotics. These medications impact neurotransmitters in the brain that are often out of balance in people with psychotic depression. In many cases, a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine (Prozac), is used along with one of the following antipsychotics:
However, these medications often take several weeks or months to be most effective.
Some people with psychotic depression may not respond to medications as well as others. In these cases, electroconvulsive therapy (ECT) may be needed to relieve symptoms. Also known as electroshock therapy, ECT has proven to be a safe, effective treatment for people with suicidal thoughts and psychotic depression symptoms. During ECT, which is generally performed by a psychiatrist, electrical currents in controlled amounts are sent into the brain. This creates a mild seizure, which impacts the levels of neurotransmitters in your brain. ECT is typically performed in a hospital under general anesthesia.
In severe cases of psychotic depression, hospitalization may be needed for a few days, especially if any suicide attempts have been made.
The outlook for someone with psychotic depression can vary depending on how quickly they receive treatment. In most cases, however, psychotic depression can be treated effectively. If you have psychotic depression, you’ll need to be persistent with your treatment because medications need to be taken for extended periods of time to prevent symptoms from coming back. You’ll also need to go to follow-up appointments continuously during treatment.
The risk of suicide is far higher in people with psychotic depression than in those with depression alone. Call 911 or go to a hospital emergency room if you have thoughts of killing yourself or harming others. You can also call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). They have trained staff available to speak to you 24 hours a day, seven days a week.
You Asked, We Answered
- How can I help someone with psychotic depression?
The most important way to help your loved one with psychotic depression is to realize that they are sick in the first place. You must also keep in mind that the delusions and hallucinations that your loved one experiences are very real to them. They can be disturbing or even terrifying for the person. Never argue that their delusion or hallucination is not real. This will only serve to upset them further and possibly prevent them from telling you what they are experiencing. Instead, adopt a patient and understanding tone with your loved one.- Timothy J. Legg, PhD, PMHNP-BC