Psychotic Depression

Major depression with psychotic features—also known as psychotic depression or delusional depression—is a serious condition requiring immediate treatment and close monitoring by a clinician.

Often, psychotic depression is mistaken for other conditions, especially bipolar disorder. A 2008 Brown University study revealed that perhaps more than half of bipolar diagnoses might be incorrect.

Symptoms common in major depression such as agitation, racing thoughts and mania are often mistaken for similar symptoms in bipolar disorder, which causes doctors to misdiagnose patients, leading to ineffective treatments and needless suffering.

Causes & Symptoms of Psychotic Depression

The causes of psychotic depression are unknown.  However, patients with a family or personal history of psychotic illness, bipolar disorder, or depression are more likely than others to develop the condition either on its own or in conjunction with other psychiatric conditions (comorbidity), such as substance abuse or anxiety disorders.

Individuals with psychotic depression have symptoms of major depression along with psychosis. Symptoms of major depression include:

  • irritability
  • difficulty concentrating
  • fatigue or lack of energy
  • feelings of hopelessness or helplessness
  • feelings of worthlessness or self-hate
  • social isolation
  • loss of interest in formerly-pleasurable activities
  • insomnia or hypersomnia
  • changes in appetite and corresponding weight loss or gain
  • suicidal ideation

Psychosis is defined as "a loss of contact with reality." Features of psychosis include:

  • delusions (false beliefs or false perceptions)
  • ?hallucinations (seeing or hearing things that are not present)

?Delusions and hallucinations are often related to the patient's depression.

Some people develop false beliefs about their own health (for instance, believing they have cancer even if they don't), while others hear voices criticizing them (e.g. "You're not good enough" or "You don't deserve to live.").

Diagnosing Psychotic Depression

Psychosis is a serious condition that may lead a person to harm himself/herself or others. A person experiencing psychotic symptoms or a caregiver who witnesses psychotic episodes should contact a doctor or mental health provider immediately. 

The first thing a doctor will do when diagnosing psychotic depression is perform a physical examination of the patient and ask questions about the person's symptoms and medical history. The doctor will also likely perform blood and urine tests—and possibly a brain scan—to rule out other medical conditions. Conditions such as obstructive sleep apnea or anemia may cause fatigue consistent with depressive symptoms.

Comorbidities must also be considered when diagnosing psychotic depression. If the patient has a family history of bipolar disorder, the doctor may screen for manic or hypomanic episodes as well.

Such an assessment doesn't necessarily confirm or discount the possibility of bipolar disorder or its comorbidity with psychotic depression, but it may help the clinician better avoid a misdiagnosis.

Treatments for Psychotic Depression

Psychotic depression is considered a "treatment resistant" form of the disease that often requires two or more attempts at treatment before a patient achieves remission.

Only a third of patients with a major depressive disorder like psychotic depression will be helped by an antidepressant on the first attempt.

A recent National Institute of Mental Health study known as Sequenced Treatment Alternatives to Relieve Depression found that patients with psychotic depression took longer to respond to treatment than those with other forms of the illness. Therefore, clinicians are encouraged to stick with a drug longer than usual (for instance, eight weeks rather than six) before switching to another medication. Persistence is key—seven in 10 patients will eventually find relief with a particular treatment. However, that leaves a third of sufferers still suffering. Because patients with psychotic depression often have a poorer response to antidepressants than others, additional treatments may be in order including antipsychotic medications or electroconvulsive therapy.

Another treatment for psychotic depression that shows promise is mifepristone (otherwise known as RU-486, the "early abortion pill"). In one study, depressive symptoms in patients taking mifepristone improved by 25 percent compared to only six percent for those taking a placebo. Another study found that nearly two-thirds of patients showed significant improvement with psychotic symptoms while taking the drug.

Electroconvulsive therapy (ECT) remains to be the primary and most effective treatment for psychotic depression. Also known as “electroshock” therapy, ECT uses pulses of electricity into the brain as a safe, effective treatment method.

Learn more about how ECT is used to treat depression at

Recovery & Prognosis of Psychotic Depression

Recovery and prognosis of psychotic depression depends on how quickly a patient receives treatment. As it is a serious condition, patients may need to remain on medication for an extended period of time to prevent symptoms from coming back. Other therapy methods, such as cognitive behavioral therapy, could increase a person’s recovery time.

In most cases, depression symptoms are more likely to return compared with psychotic features of the disorder.

Suicide Risk

The risk of suicide is far higher in people with psychotic depression than in those with depression alone. If you have thoughts of killing yourself or harming others call 911, go to a hospital emergency room or call the National Suicide Prevention Lifeline, 24 hours a day, 7 days a week at 1-800-273-TALK (1-800-274-8255).