Psychotic depression refers to major depressive disorder (MDD) with features of psychosis, a specific presentation of depression. It involves symptoms of psychosis during an episode of depression.
Psychosis can include:
Estimates based on community samples suggest MDD with psychosis affects anywhere from 10 to 19 percent of people having an episode of major depression. Among people receiving inpatient care for depression, this rate increases to:
- between 25 and 45 percent of adults
- up to 53 percent of older adults
Some experts believe MDD with psychosis may actually occur at higher rates, since clinicians don’t always recognize psychosis when diagnosing depression.
In fact, a 2008 study considering data from four different medical centers found that clinicians misdiagnosed this condition
Psychotic depression vs. major depression
MDD, or clinical depression, can affect your mood, behavior, everyday life, and physical health.
An episode of major depression typically involves:
- a persistent low mood or a loss of interest in everyday life for at least 2 weeks
- four or more other symptoms of depression (more on these symptoms in the next section)
Psychosis isn’t included in the nine main symptoms of depression, and many people living with MDD never experience psychosis.
The most recent edition of the “Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)” classifies the two separately, listing depression with features of psychosis as “Other Specified Depressive Disorder.”
Depression is always serious. Still, experts tend to consider MDD with psychosis more serious than depression without psychosis because it’s more likely to involve:
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Depression with delusions and hallucinations can feel very frightening, especially when these beliefs and perceptions suggest you should hurt yourself or someone else.
If you’re having thoughts of suicide, know that help is available.
You can reach a trained counselor at any time of day by:
- calling 800-273-8255 to reach the National Suicide Prevention Lifeline
- texting HOME to 741-741 to reach the Crisis Text Line
If you need help to stay safe, contact a trusted loved one or a local mental health clinic or psychiatric hospital.
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If you have MDD with psychosis, you’ll have symptoms of both major depression and psychosis.
The symptoms of major depression include:
- a persistent low, empty, sad, or hopeless mood (some people may believe life is no longer worth living, but others might feel more irritable than sad)
- loss of interest and pleasure in activities you used to enjoy
- sudden or unexplained changes in appetite and weight
- sleeping difficulties, including sleeping much more or much less than usual
- less energy than usual or lingering fatigue
- changes in movement, such as increased restlessness or a sense of being slowed down
- difficulty concentrating or making decisions
- frequent feelings of worthlessness, helplessness, self-hatred, or guilt
- frequent thoughts of death, dying, or suicide
Psychosis involves a break or disconnect from reality, so people experiencing it aren’t necessarily aware of their symptoms, which can include:
- hallucinations, or seeing, hearing, and feeling things that aren’t real
- delusions, or believing things that aren’t true
- psychomotor impairment, or slowed thoughts, movements, and feelings
- a state of stupor, where you’re unable to move, speak, or respond to your environment
Psychotic hallucinations and delusions might involve:
- believing you have a serious health concern, despite multiple tests showing otherwise
- believing you have unique or special powers
- believing you’re a famous person or historical figure
- hearing voices criticizing or mocking you
- seeing a frightening or threatening animal following you
- paranoia, or an irrational or extreme suspicion of other people
Delusions, with or without hallucinations, happen more often than hallucinations alone in people experiencing psychotic depression.
Experts separate MDD with features of psychosis into two categories:
- MDD with mood-congruent psychotic features. Hallucinations and delusions reflect feelings and emotions that often show up with depression, including feelings of personal inadequacy, worthlessness, guilt, and fears about illness or death.
- MDD with mood-incongruent psychotic features. Hallucinations and delusions conflict with depression-related emotions. You might hallucinate a loved one, hear voices praising you, or smell something pleasant. You might also believe someone is trying to chase you, kidnap you, or control your thoughts.
You can have both mood-congruent and mood-incongruent symptoms. In the past, experts associated mood-incongruent features of psychosis with worse outcomes. Recent research suggests this isn’t necessarily the case.
Delusions and hallucinations often feel completely real. They can lead to terror, panic, and extreme distress.
Some people experiencing psychosis end up hurting themselves or others in an effort to make the symptoms stop. That’s what makes it so important to seek help for psychosis right away.
Researchers have yet to identify a single specific cause of MDD with psychosis, or any type of depression, for that matter.
Possible causes include:
- Genetics. You’re more likely to develop depression if a first-degree relative, like a parent or sibling, also has depression.
- Biology and brain chemistry. Imbalances in brain chemicals like dopamine and serotonin play a role in many mental health conditions, including depression and psychosis. Some
evidencealso suggests higher levels of the stress hormone, cortisol, may play a part.
- Environmental factors. Traumatic or stressful experiences, particularly in childhood, can also raise your chances of experiencing depression.
To date, not a lot of research has explored unique risk factors for MDD with psychosis.
- not having close friends or loved ones to confide in
- infrequent contact with friends and family
- a family history of any mental health condition
- a major negative life event in the past year
Other factors that could raise your chances of developing the condition include:
- major hormonal changes, such as during the postpartum period or menopause
- surviving extreme stress or trauma
- living with chronic pain or other chronic health conditions
- ongoing financial difficulties
- gender (
cisgender womenand transgender people of any gender have a higher risk of depression)
- age (older adults have a higher risk of MDD with psychosis)
- a family history of bipolar disorder with psychosis, schizophrenia, or MDD with psychosis
People experiencing depression with psychosis don’t always seek help on their own. In some cases, it might be a family member or close friend who helps them find a medical or mental health professional who can make a diagnosis.
To make a diagnosis, they’ll generally start by asking questions about your mental health, mood, and emotional well-being. They might ask about:
- fixed beliefs or persistent worries that affect your daily life
- things you see, hear, or feel that no one else seems to notice
- problems with sleeping, eating, or going about your daily life
- your support network and social relationships
- health concerns
- other mental health symptoms, like anxiety or mania
- your personal and family health and mental health history
Psychosis isn’t always obvious, even to trained clinicians. Some mental health professionals may not immediately recognize the difference between fixed delusions and rumination, a pattern of looping sad, dark, or unwanted thoughts.
Both delusions and rumination, which is common with depression, can involve:
- fears of rejection
- concern for your health
- guilt over mistakes you believe you’ve made
- perceptions of yourself as a failed partner or parent
Describing all of your feelings, perceptions, and beliefs to your clinician can help them make the right diagnosis.
A diagnosis of major depression also requires that symptoms:
- last for 2 weeks or longer
- affect some areas of daily life
- aren’t related to substance use or another condition
A note on severity
MDD can be mild, moderate, or severe, based on the number of symptoms you have and how they affect daily life.
In the past, experts associated psychosis with severe major depression. Severe MDD involves most of the main symptoms of depression, which typically:
- have a major impact on daily life
- cause significant distress
- resist management and treatment
The DSM-5 considers severity and specifiers, like psychosis, separately.
In other words, you can have a “mild” episode of depression, with fewer symptoms that don’t majorly affect day-to-day life, and still experience psychosis. Dysthymia, or persistent depression, can also involve psychosis.
If you experience both depression and psychosis, you’ll want to get support from a mental health professional right away. This condition typically doesn’t improve without professional treatment.
Your care team may recommend a short stay in a psychiatric hospital to treat severe psychosis and persistent thoughts of self-harm or suicide.
Treatment for psychotic depression generally involves psychotropic medications, though you have other options, too.
Your psychiatrist or doctor might, for example, prescribe a selective serotonin reuptake inhibitor (SSRI) along with one of the following antipsychotics:
They can also provide more information about medication options, help you find the right medication and dose, and offer guidance on possible side effects.
These medications can begin working right away, but you might not notice their full effects for several weeks.
Electroconvulsive therapy (ECT)
Your care team may also recommend ECT for severe depression that doesn’t respond to medication or therapy.
You’ll typically receive ECT in a hospital while under anesthesia. This treatment involves a series of treatments that stimulate your brain with a controlled voltage of electrical current. The current creates a mild seizure, which affects the levels of neurotransmitters in your brain.
While it’s considered safe and generally effective for people experiencing thoughts of suicide, psychosis, and catatonia, ECT does involve a few possible risks, including:
- short-term memory loss
Your care team will explain more about these risks before you begin treatment.
ECT may not keep your symptoms from coming back entirely, so your psychiatrist will likely recommend ongoing treatment in the form of therapy, medication, or both. They may also recommend future ECT treatments.
While therapy alone may not do much to improve symptoms of psychosis on its own, it can still have benefit as a supportive approach.
Therapy offers a safe space to share distressing emotions and experiences, for one. A therapist can also teach strategies for coping with hallucinations and delusions.
Possible approaches include:
- cognitive behavioral therapy
- acceptance and commitment therapy
- behavioral activation
- acceptance-based depression and psychosis therapy
MDD with psychosis can sometimes resemble schizophrenia, another mental health condition that involves psychosis. The main difference lies in when psychosis shows up:
- If you have MDD with psychosis, you’ll only have symptoms of psychosis during an episode of depression.
- If you have schizophrenia, you’ll have symptoms of psychosis whether you have depression symptoms or not.
While schizophrenia doesn’t always involve depression, many people living with schizophrenia do have symptoms of depression, which can complicate diagnosis of either condition.
But schizophrenia involves other symptoms not necessarily associated with depression, including:
- disorganized or incoherent speech
- lack of emotional expression
Some people diagnosed with MDD with psychosis later receive a diagnosis of schizophrenia or bipolar disorder with psychosis. This appears more likely for people:
MDD with psychosis is a serious mental health condition that requires prompt treatment from a trained mental health professional. You do have options for treatment, and the right approach can improve symptoms of both depression and psychosis.
Finding the most effective treatment may take some time, and it’s important to share any persistent symptoms or side effects with your care team. They can help you manage side effects and explore alternate treatments, if needed.
Keep in mind, too, that friends and loved ones can also offer support.