Mood symptoms can be expected in schizophrenia, but many people don’t realize how common it is to live with schizophrenia and depression.
Receiving a schizophrenia diagnosis can feel daunting. It generally means you’ve been experiencing symptoms of psychosis — episodes when your brain is unable to distinguish between what’s real and what isn’t.
Along with symptoms of psychosis, you may feel a rush of negative emotions. Schizophrenia’s onset can be unsettling before you know what’s happening, and even after diagnosis, many challenges can remain.
It’s not out of the ordinary to have low mood and feelings of anxiety.
Schizophrenia and depression are a common mix, but how and when mood symptoms present determines your formal diagnosis.
It’s possible to have both schizophrenia and depression. In fact, depression is fairly common among people living with schizophrenia.
In a 2020 meta-analysis that included more than 9,800 people living with schizophrenia around the world, 28.6% of them also had depression.
How symptoms of depression manifest matters when it comes to schizophrenia. It’s what determines if you’re experiencing:
- schizoaffective disorder, depressed type
- depression with features of psychosis
- schizophrenia with episodes of depression
Schizoaffective disorder, depressed type
Dr. David Feifel, an emeritus professor of psychiatry at the University of California, San Diego, explains a schizoaffective disorder, depressed type diagnosis occurs when you:
- meet the diagnostic criteria for schizophrenia and major depressive disorder (MDD)
- have chronic symptoms of depression
In other words, rather than receiving a diagnosis of schizophrenia and MDD separately, having both these chronic conditions is called schizoaffective disorder.
“If depression is not a chronic feature, it’s schizophrenia with episodes of clinical depression,” Feifel says. “Importantly, in both cases the psychosis is a primary feature and not an outgrowth of the depression.”
In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR), two specifiers help categorize schizoaffective disorder:
- depressed type
- bipolar type
In depressed type, you’re only experiencing major depressive episodes. In bipolar type, periods of elevated, agitated mood known as mania are also present.
Major depressive disorder with features of psychosis
Depression that meets the diagnostic criteria for MDD but has episodes of psychosis is known as major depressive disorder with features of psychosis.
In the DSM-5-TR, this diagnosis means you’re primarily experiencing MDD. Episodes of psychosis aren’t persistent and aren’t a dominant feature of your symptoms.
Feifel says psychosis in MDD comes from experiencing symptoms that reach high levels of severity. He likens it to a fever analogy.
“Think of delirium due to a fever; it isn’t going to occur with a mild or even moderate fever but may [occur] if the fever reaches extreme levels,” he says.
In addition, Feifel explains symptoms of psychosis in MDD tend to show differently than those in schizophrenia and are typically congruent with feelings of depression.
“Examples of this are delusional beliefs that one is dying or already dead (Cotard’s syndrome), feeling guilt due to distorted recollections of past behavior, or entrenched beliefs of inadequacy that don’t comport with reality,” he says. “We call this ‘mood-congruent psychosis.’”
It’s also possible to experience mood-incongruent psychosis in MDD.
The DSM-5-TR classifies schizophrenia as a type of psychotic disorder. Its main diagnostic feature is the presence of symptoms of psychosis, including hallucinations and delusions. You don’t have to be experiencing mood symptoms to receive a schizophrenia diagnosis.
Depression is a mood disorder. Its primary features are related to low mood and diminished experiences of joy. Symptoms of psychosis aren’t a part of the main diagnostic criteria.
“Schizophrenia is essentially a disorder of thinking, where external information is interpreted by the brain in a distorted way; whereas, depression is a disorder of feeling, where the brain regions responsible for reacting with pleasure and optimism (hedonia) are malfunctioning,” says Feifel.
Symptoms of schizophrenia
Schizophrenia’s diagnostic criteria in the DSM-5-TR are made up of two types of symptoms:
- Positive: symptoms that add to existing ability
- Negative: symptoms that show a loss of ability or function
Positive symptoms include:
- disorganized thinking (also called disorganized speech)
- disorganized motor function
Negative symptoms include:
- diminished pleasure response and capacity (anhedonia)
- less speech output (alogia)
- diminished emotional expression
- disinterest in social interactions (asociality)
- lack of motivation toward purposeful activities (avolition)
To receive a schizophrenia diagnosis, two or more symptoms must be present for the majority of a month’s time, with one of those symptoms being hallucinations, disorganized thoughts, or delusions.
Symptoms of major depressive disorder
Diagnostic criteria for MDD in the DSM-5-TR involve experiencing five or more of the following symptoms during the same 2-week time frame. At least one of the symptoms must be depressed mood or loss of interest or pleasure:
- depressed mood nearly every day, all day
- notably diminished interest or pleasure in almost all activities, all day, for most days
- changes in motor function
- persistent fatigue
- sleeping too much or too little
- weight fluctuations
- trouble concentrating nearly every day
- suicide ideation or thoughts of death
- feelings of worthlessness or inappropriate guilt
Schizoaffective disorder treatment involves managing the symptoms of psychosis in schizophrenia and treating the mood symptoms in MDD.
Medications can typically treat schizoaffective disorder, such as:
- mood stabilizers
You may also benefit from psychotherapy options, including:
- psychosocial strategies
- cognitive behavioral therapy (CBT)
- electroconvulsive therapy (ECT)
Depression with features of psychosis
In the case of MDD with features of psychosis, Feifel says “treating depression effectively is key since that will bring about a reduction in the psychosis.”
Treatment of MDD often involves the use medications, such as:
- mood stabilizers
If features of psychosis are currently present, a doctor may prescribe antipsychotic medications.
Psychotherapy that can help treat MDD includes:
- interpersonal therapy
- transcranial magnetic stimulation (TMS)
- vagus nerve stimulation (VNS)
Schizophrenia with episodes of depression
If you’re experiencing schizophrenia with major depressive episodes, your treatment may also involve an approach focused on the primary condition and addressing mood symptoms as they occur.
- antipsychotic medications
- psychosocial support strategies
It’s common to have both schizophrenia and depression. When you meet the diagnostic criteria for both schizophrenia and major depressive disorder, you’re living with schizoaffective disorder.
How your symptoms emerge will determine your diagnosis and the treatment path your healthcare team recommends.
Medications and psychotherapy approaches are available no matter how schizophrenia and depression blend into your life.