Psychotic Depression

In this article, we explore how psychotic depression is diagnosed, as well as what the symptoms, causes, and available treatment options are.

Key Takeaways

• Psychotic depression is a serious condition that manifests as major depression with episodes of psychosis (delusions or hallucinations). These psychotic symptoms may align with or differ from an individual’s depressive mood.

• The disorder is not recognized as a standalone condition in the DSM-5, leading to frequent misdiagnosis. Additionally, there is ongoing debate as to whether psychotic depression is a subtype of psychosis, a subtype of depression, or a separate disorder.

• While research on treatment is limited, the most promising findings combine antidepressants, antipsychotics, and electroconvulsive therapy (ECT). Psychotherapy, self-compassion, connection, and purpose also support ongoing recovery, especially in rebuilding self-trust.

What is Psychotic Depression?

Depression is a mental health condition characterized by persistent sadness, loss of interest in activities, and other symptoms that interfere with daily life. In certain cases, depression is accompanied by psychotic episodes, which cause the sufferer to believe, hear, smell, taste, or see things that are not real.

Psychosis not only occurs in people with depression but is linked to substance use and other mental health conditions as well. The key difference between psychotic depression and other psychotic disorders, is that people who have depression with psychotic features are often (but not always) aware that their thoughts are irrational.

The term “depressive disorder with psychotic features” appears in the Diagnostic and Statistical Manual for Mental Health, Fifth Edition (DSM-5) 11 times, but is not classified as a standalone disorder. This is due to the fact that the condition was previously believed to be a manifestation of severe major depression, which exists on a spectrum.^[2]

However, recent research shows that psychosis is an independent trait, meaning that it is not just a side effect of severe mood disorders like major depression. Instead, it appears to be a separate feature of mood disorders - as it does not manifest in everyone with depression or other mental health conditions.^[2]

That being said, researchers are unsure whether depression with psychosis should be classified as a subtype of psychosis, a form of depression, or as a separate condition entirely. Not much is known about psychotic depression with brief or mild psychotic episodes, psychotic symptoms that do not align with an individual's low mood, or psychoses linked to past trauma.^[2][3]

Who Does it Affect?

Understanding depression with psychotic features remains difficult, with studies indicating a need for improvement in how the condition is identified, as it is often misdiagnosed. This has led to obstacles in research due to limited knowledge on who is affected (prevalence) in diverse and representative groups.^[3]

When investigating prevalence in a disorder, researchers often prefer to study people who have just been diagnosed, as studying long-term cases can give an inaccurate picture. This is due to the fact that people with persistent symptoms tend to be more severely affected, whereas others who may experience fleeting bouts of psychotic episodes are not taken into account.^[3]

That being said, psychotic major depression (PMD) is estimated to affect about 4 in every 1,000 people, which is just less than the prevalence of schizophrenia. Some studies suggest that PMD may occur as often (or even more often) than other psychotic disorders like schizophrenia, although other research disagrees, likely due to differences in methodology.^[3]

In the most recent systematic review investigating psychotic depression (conducted in 2017), it was found that higher rates of psychotic depression are observed in older adults. The study also suggested that there are no significant differences in the prevalence of psychotic depression between men and women compared to non-psychotic depression.^[4]

Symptoms of Psychotic Depression

Psychotic depression is a serious condition where a person experiences both depression and psychosis. The condition is listed under the “Other Specified Depressive Disorder” section in the DSM-5, meaning that it is not linked to any particular depressive disorder and can potentially manifest in all subtypes of depression.^[1]

Symptoms of Depression

Depression is a mental health condition that can distort how an individual perceives themselves, their life, and the world around them. The disorder makes everything feel negative, and it can be hard to believe that things will ever get better. In adolescents, depression can be harder to spot. It may show up as problems at school, changes in behavior, or drug and alcohol use.^[1]

Common depressive disorder symptoms include:^[1]

• Feeling agitated, restless, angry, or easily irritated.

• Pulling away from others or avoiding social contact.

• Feeling tired or drained all the time.

• Hopelessness, guilt, low self-worth, or self-hate.

• Losing interest in things that used to bring enjoyment (including sex).

• Sudden changes in appetite and weight.

• Challenges with sleeping too little or too much.

• Difficulty focusing or making decisions.

• Thoughts of suicide or death.

Symptoms of Psychosis

A psychotic episode can be thought of as a period of insanity where a person cannot function due to symptoms like delusions, hallucinations, and paranoia. These unreal beliefs can cause a person with psychosis to doubt their perception of reality.^[1]

The main symptoms of psychosis are:^[1]

• Delusions: Strong, false beliefs that seem to be one hundred percent real to the psychotic individual (like believing that one has a serious illness or that one possesses superhuman powers when this is not the case).

• Hallucinations: Seeing or hearing things that are not real (like a building on fire, oil spills on a road, sounds of voices or animals, or anything that isn’t rooted in reality).

• Paranoia: Believing that threatening situations are taking place (e.g. an individual is convinced that doctors and professionals are involved in a plot to harm or kill them)

In depression with psychosis, paranoia, hallucinations and delusions can either align with the individual’s mood (for example, involving themes like guilt, death, or hopelessness), or they can seem unrelated to the person's depressed mood (such as feeling watched, controlled by outside forces, or having thoughts put into their mind).^[3]

When psychotic symptoms align with a depressive mood, they are known as mood-congruent, and when they are not related, they are referred to as mood-incongruent. In psychotic depression, hallucinations and delusions are usually mood-congruent. For example, someone might hear voices putting them down or falsely believe their body is diseased or broken.^[1][3]

Keep in mind that the severity of psychotic episodes can vary from individual to individual, with some people being aware of their irrational thoughts and others lacking insight. In other words, one person with psychotic depression might keep false beliefs to themselves, while another acts on their paranoid delusions or hallucinations.^[3]

Signs of Psychotic Depression

When it comes to symptoms of depression, like crying for no significant reason, self-harm, or attempting suicide, it is easy to recognize. However, depression with psychotic features may be harder to identify if an individual with the condition is aware of their irrational thoughts and intentionally conceals them.

Psychotic symptoms can vary widely, with a selection of people even experiencing euphoric delusions (such as believing they are a Sun God). However, the majority of people with psychotic depression experience disturbing and paranoid hallucinations or delusions that reflect a low mood.

Here are a few signs of psychotic depression:

• Frequent despair and crying spells for no significant reason.

• Attempts to self-harm or commit suicide.

• Daily function is impaired at work, school, or home.

• Feeling as if one is having thoughts that would sound “crazy” to others.

• Being convinced of having a serious illness, even when medical tests prove otherwise.

• Thinking one has special abilities or powers that others don’t.

• Believing one is famous or a historical character.

• Hearing insulting voices.

• Seeing a terrifying animal that seems to be following you.

• Feeling extremely suspicious of others, including doctors and family, without a clear reason.

• Believing one is being spied on, tracked, stalked, or hacked.

• Thinking others wish them harm.

• Extreme guilt and fear of persecution.

• Believing one is experiencing, or about to experience, poverty.

Causes of Psychotic Depression

In light of the fact that depression with psychotic features has primarily been studied in people who have had the condition for a long time, the exact cause of this disorder is not known. When trying to understand what causes a mental health condition, researchers often prefer to study newly diagnosed cases so as to examine evidence that reflects more comprehensive statistics.^[3]

Due to the fact that this psychotic depression is frequently misdiagnosed, the data is not sufficient for researchers to thoroughly investigate the cause. That being said, having a personal or family history of depression or psychotic disorders is thought to increase the chances of developing this condition.^[1][3]

However, although the exact cause of psychotic depression remains a mystery, depression itself has been shown to arise from a combination of factors. These influences are thought to feed into each other, and include biological, psychological, environmental, and social influences such as:^[5]

• Inflammation

• Genetic vulnerabilities

• Brain chemical imbalances

• Negative self-concept

• Rumination

• Maladaptive coping styles

• Adverse life events

• Low socioeconomic status

• Lack of support

Similarly, in terms of what triggers a psychotic episode, it often results from a combination of biological and environmental factors. Additionally, psychosis may occur as part of a mental illness or as a symptom of physical conditions, especially in older adults. It can also be triggered by lifestyle factors, medication side effects, or substance use.^[6]

• Genetic vulnerability and differences in brain development

• High levels of stress or exposure to trauma

• Mental illnesses (such as schizophrenia, bipolar disorder, or psychotic depression)

• Brain conditions linked to aging (including Parkinson’s disease, Alzheimer’s disease, and related dementias)

• Sleep deprivation

• Side effects of certain prescription medications

• Alcohol or drug abuse

Is it Preventable?

Keeping in mind that the primary theory for the cause of psychotic depression is personal or family history, there is no way to prevent the disorder at this stage. However, it is important to be aware that several substances (some of which are legal) can induce psychosis - although this would be diagnosed as substance-induced psychotic disorder - even in people with depression.

In light of the strong link between mental health conditions and substance use, it is recommended for individuals with depression to avoid self-medicating with substances. Abusing substances can further compromise abnormal brain chemistry and may even lead to a psychotic episode. Substances that have been linked to psychosis include:^[7][8]

• Cannabis

• Cocaine

• Amphetamine (speed)

• Methamphetamine (crystal meth)

• Mephedrone (MCAT or miaow)

• MDMA (ecstasy)

• Ketamine

• LSD (acid)

• Psilocybin (magic mushrooms)

Risk Factors and Complications

Research has explored how psychotic depression may develop into other mental health conditions. One study found that the older a person was when symptoms began, the less likely they were to be diagnosed with bipolar disorder later on. Another found that younger people with depression were more likely to develop schizophrenia later in life.^[3]

Compared to non-psychotic depression, people with psychotic major depression (PMD) tend to experience more severe thought-processing and memory problems, have a higher chance of the illness returning, are less functional socially, and report a lower quality of life. Additionally, the condition is linked to a higher risk of suicide.^[9]

In fact, people with psychotic depression were found to be at double the risk of suicide compared to those who had severe depression without psychosis. Suicides among this group were more likely to involve violent methods, with the highest risks linked to deaths by impact (like jumping from heights) and suffocation (such as hanging).^[10]

Suicide Hotlines

If you or someone you know is having suicidal thoughts or is planning to attempt suicide, it is imperative to seek help right away. In the United States, you can reach the suicide and crisis hotline by calling 988, and additional resources for veterans, youth, and Spanish-speaking individuals are available here.

For support outside the U.S., you can find international suicide hotline numbers through this link. If your country is not listed, search for "suicide hotline" along with your country’s name for immediate assistance. Keep in mind that people experiencing a psychotic episode may not realize their beliefs are not real, and when this is linked to suicide, hospitalization is crucial.

Diagnosing Psychotic Depression

As psychotic depression is not a standalone disorder in the DSM-5, many healthcare professionals find it difficult to diagnose. Fortunately, the classification of mental health disorders is still evolving, which may lead to more accurate diagnoses in the future and significantly influence both clinical practice and research approaches.^[3]

However, in light of the frequent misdiagnosis of psychotic depression, several strategies have been suggested by researchers to improve the detection of psychotic symptoms in patients with depression. These include asking patients about any “irrational worries” as a gentle method of exploring possible psychotic beliefs, making it easier for patients to open up.^[3]

Another approach involves asking for permission to speak with family members, who may be able to report unusual thoughts, experiences, or signs of paranoia that the patient has not disclosed. Modified assessment tools have also been proposed to help identify psychotic symptoms more effectively.^[3]

That being said, these methods haven’t been thoroughly tested for accuracy, so their reliability is still uncertain. Even so, they could still be useful in helping both mental health specialists and general practitioners spot cases of psychotic major depression more effectively, especially in people who initially present with depression.^[3]

Assessments and Tests

Assessing how severe a person’s symptoms are is crucial, as it can help with monitoring the disorder over time. Most current tools are designed to measure either depression or psychosis, but not both together. To address this, the Psychotic Depression Assessment Scale (PDAS) was developed in 2014.^[3]

This assessment combines relevant items from two well-known rating scales and has proven effective at measuring the overall severity of psychotic depression. The PDAS may serve as a useful screening tool for identifying PMD among patients who initially appear to have non-psychotic depression.^[3]

Healthcare providers are likely to conduct a physical exam and ask about the individual’s health history and current symptoms. They may also order blood and urine tests, or possibly a brain scan, to rule out other medical issues that could be causing similar symptoms to depression with psychotic features.^[1]

Challenges and Misdiagnosis

The National Collaborating Centre for Mental Health has noted that PMD is often misdiagnosed because the psychotic symptoms can be subtle, come and go, or be deliberately hidden. In fact, people with psychotic depression tend to realize that their thoughts are unusual and keep these experiences to themselves, which sets them apart from many others struggling with psychosis.^[3]

Additionally, in a study of 130 cases, psychotic depression had not been diagnosed prior to research assessments in 27% of patients. The most common misdiagnoses were major depressive disorder without psychotic features, depression not otherwise specified, and mood disorder not otherwise specified.^[11]

Psychotic depression was more likely to be missed when symptoms like low mood, hallucinations, or delusions were not recorded in the medical notes. However, the missed diagnoses are mainly due to psychotic features being overlooked, with depressive symptoms being fairly easy to pinpoint.^[3][11]

Clinicians may notice symptoms like guilt or fear of poverty but fail to recognize them as delusions, leading to inappropriate treatment and a risk that the condition may worsen.

Although frequently misdiagnosed in both settings, diagnoses for psychotic depression were found to be more accurate in inpatient settings than in emergency rooms.^[3][11]

Treatment Options

Psychotic depression is a serious condition that requires urgent medical attention and professional support. If you have noticed that a loved one is psychotic, harming themselves, or feeling suicidal, it is best to book them into a psychiatric facility for immediate intervention.

A treatment center can help an individual with psychotic depression to stabilize with treatments like medication and therapy. While strong research on treatment options for psychotic depression is limited, a combination of medication and electroconvulsive therapy (ECT) shows the most promise.^[2][3]

Psychiatric Institutions

An in-patient psychiatric institution can be a lifeline for someone with severe psychotic depression to recover from delusions, hallucinations, and paranoia. Being in a facility can also help to protect the individual from self-harm or suicide during a high-risk period.

In-patient facilities offer the close monitoring of symptoms by medical professionals (including psychiatrists, psychologists, and nurses) who can keep the individual safe and work together to create a personalized treatment plan.

Medications such as antidepressants and antipsychotics can be carefully adjusted under supervision to reduce symptoms and improve stability. It is recommended to research a psychiatric institution that offers electroconvulsive therapy (ECT).

Medication

Research has revealed that psychotic depression tends to respond poorly to using either antidepressants or antipsychotics alone. However, better outcomes have been seen when both medications are combined, especially when used with ECT.^[9]

A meta-analysis confirms that while the combination of antidepressants and antipsychotics performed better than either medication alone, the differences were not as statistically significant as using both medications combined with ECT.^[3]

Psychotic depression can be long-lasting, and once psychotic symptoms stabilize, individuals may need to stay on medication for a while to prevent relapse. It is more common for depressive symptoms to return than psychotic ones.^[1]

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy is a medical treatment where small electric currents are passed through the brain to trigger a brief, controlled seizure. ECT is done under general anesthesia and is considered safe and effective when carefully monitored by trained professionals.

ECT is particularly effective in older adults with psychotic depression and is recommended as a first-line treatment in several clinical guidelines. While its underlying brain mechanisms are still not well understood, ECT is especially effective for severe cases with psychotic symptoms.^[1][9]

Living with Psychotic Depression

Psychotic episodes can cause a person to doubt their perception of reality, even if they are no longer psychotic. Experiencing psychosis is akin to being betrayed by one’s own mind, and as a result, can erode self-trust significantly. The journey to mental wellness looks different for everyone, with some individuals struggling with psychotic depression more than others.

A psychologist by the name of Joyce Vroman, who experienced depression with psychotic features first hand, wrote that self-compassion, therapy, connection, and purpose help her to rebuild trust in herself more every day. Let us take a look at how these pillars support living with psychotic depression:

Self-Compassion

When it comes to mental health, self-compassion can go a long way. Instead of beating yourself up about having a brain condition, try to speak to your inner child with kindness and care. Tell yourself that it is okay to seek help and that your condition does not define you.

If your disorder prevents you from speaking to yourself with compassion, practice affirmations to self-soothe. Affirmations can serve as a powerful reminder of your strengths, which can help you view yourself more positively, and may even build self-compassion and trust.

Therapy

Cognitive behavioral therapy (CBT) can help to rebuild self-compassion and trust by teaching individuals to reframe negative thoughts. While CBT cannot reduce psychotic symptoms, this form of therapy is excellent for mental health maintenance during periods of lucidity.

CBT can help individuals who have had psychotic bouts of depression to address fears of reoccurring episodes. It also provides a safe space to process any work or relationship issues that may have arisen as a result of psychotic depression.

Connection

There are a large number of studies that highlight the importance of social support, or community, for optimal mental well-being. While family and friends can help if you need an objective opinion on whether your thoughts are rational or not, support groups offer the benefit of relatability, which can ease the guilt and shame of social stigma.^[12]

In other words, finding a support group for psychosis or depression can allow you to talk about your experiences to people who understand and accept you in your entirety. You might even find yourself laughing about the craziness of your condition, which can be a very healing experience. The Schizophrenia and Psychosis Action Alliance offers free international online support groups here.

Purpose

Studies have found that having a sense of purpose can reduce depression and build optimism. Finding purpose in life doesn’t have to take the form of anything particularly grand. Simply doing your best to be of service by helping others can transform your view of your place in the world.^[13]

This could look like making tea for a loved one, helping a friend choose a pair of spectacles, or volunteering to get more involved with a support group. There are an infinite number of opportunities to direct your energies towards the greater good and in so doing, support your mental health.

Final Thoughts

Psychotic depression is a complex condition that challenges both individuals and clinicians due to its dual presentation of mood and psychotic symptoms. The disorder is commonly misdiagnosed, with an ongoing debate surrounding its classification in the DSM-5. Additionally, many people with the condition intentionally conceal their symptoms from healthcare providers.

Although there is limited research on treatments for psychotic depression, medication (anti-depressants and anti-psychotics) combined with electroconvulsive therapy show promising results. While recovery may not be linear, support groups, psychotherapy, and a compassionate, informed approach offer hope for living a meaningful life beyond the limitations of the disorder.