What is Psychotic Depression?

Major depression with psychotic features, or psychotic depression, is a form of depression that also involves the symptoms of psychosis.

The term psychosis refers to conditions that affect a person’s mind, causing them to lose some level of connection with reality. A person with psychosis may develop delusions (false beliefs) and hallucinations in addition to the symptoms of depression. 

Psychotic depression is a serious mental illness that requires immediate care. Like other forms of depression, it’s usually treatable with a combination of medication and other approaches.

Below, we’ve explained what psychotic depression is, as well as the symptoms you may have if you’re affected by depression that involves psychosis. 

We’ve also discussed the normal diagnosis and treatment process for psychotic depression, as well as the long-term outlook for this form of mental illness.

Psychotic depression is a term that’s used to refer to a depressive episode that involves certain features of psychosis, or loss of touch with reality.

Clinically, psychotic depression is typically referred to as psychotic major depression (PMD), or major depression with psychotic features. Because it often involves delusional thoughts, it may also be referred to as “delusional depression.”

Psychotic depression is a form of severe depression that can have a large impact on a person’s quality of life and ability to function.

Depression with psychotic features or psychotic symptoms is relatively uncommon. In one study involving 2,500 people with major depression, approximately 5.3 percent had features of psychosis.

More recent research involving community samples suggests that 10 percent to 19 percent of all adults who experience major depressive episodes display some symptoms of psychosis. 

Common symptoms of clinical depression include:

• A persistently sad, empty or anxious mood

• Irritability and a “shorter fuse”

• Overly pessimistic or hopeless feelings

• Reduced interest in hobbies and other activities

• A sense of worthlessness, helplessness or guilt

• Anhedonia (a reduced ability to experience pleasure)

• Slowed movements and/or speech

• Difficulty falling asleep, staying asleep or waking up at a normal time

• Aches, pains, cramps, headaches and other physical symptoms

• A general loss of energy and feeling of physical and mental fatigue

• Difficulty focusing on specific tasks or remembering information

• Changes in appetite, eating habits and/or body weight

• A reduced ability to make decisions

• Suicidal thoughts and/or behaviors

In order to be diagnosed with depression, you’ll generally need to have several of the symptoms above for a period of at least two weeks in addition to a depressed mood.

Psychotic depression involves the depressive symptoms listed above in combination with one or several psychotic symptoms. Common symptoms of psychosis include:

• Delusions (false beliefs that do not conform with reality)

• Hallucinations (hearing or seeing things that do not exist)

These symptoms often result in changes in a person’s behavior. If you develop one or several of the following changes, it may be a signal that you’re affected by some degree of psychosis:

• A sudden decline in your career or educational performance

• Social withdrawal and a general lack of interest in being around other people

• Difficulty communicating with others and an increase in confused speech

• Ideas and beliefs that are overly suspicious, paranoid or conspiratorial

• Difficulty distinguishing between real life and fantasy 

• Unusual feelings or an almost complete lack of any feelings

• A decline in your level of self-care, personal hygiene and self presentation

The majority of people affected by psychotic depression experience delusions — fixed, specific beliefs that aren’t changed by logical thinking techniques or exposure to contrary evidence. A smaller percentage of people with psychotic depression experience hallucinations. 

Symptoms of psychosis may be mood-congruent, meaning they’re consistent with a depressed person’s thoughts and feelings, or mood-incongruent, meaning they have content that conflicts with a person’s thoughts and feelings.

For example, a person with depression and mood-congruent psychotic features might have one or several delusional beliefs about their guilt, impending doom or personal inadequacies.

In contrast, a person with depression and mood-incongruent psychotic features might think that they have superpowers or that they’re the target of an unrealistic conspiracy. 

Psychotic depression is usually more debilitating than major depression, meaning it has a more significant negative impact on people’s wellbeing. This is because many symptoms of psychosis can feel extremely real when they’re occurring.

According to research, people with psychotic depression are more likely to have poor outcomes, including a greater degree of functional impairment, more residual symptoms and more frequent attempts at suicide. 

Researchers haven’t yet been able to find a single precise cause of depression, or psychotic depression. Currently, most research suggests that a mix of genetic, biological, psychological and environmental factors can play a role in the development of depression.

Certain factors may increase your risk of developing a depressive disorder such as psychotic depression. Risk factors for depression include:

• Family members with depression. Depression is partly caused by genetic factors, meaning it can potentially run in families. You may have a higher risk of experiencing depression if one of your close family members has suffered from depression.

• A personal history of depression. Depression often comes back — an issue that’s referred to as a depression relapse. You may be more at risk of developing psychotic depression or other mood disorders if you’ve been depressed before.

• Serious medical illnesses. Some illnesses, such as diabetes, heart disease, cancer and Parkinson’s disease, are associated with depression. Some medications used to treat these conditions may also increase your risk of becoming depressed.

• Abrupt negative changes to your life. Depressive and other mental disorders often develop after sudden, unexpected negative changes in life. You may be more likely to become depressed after a traumatic or stressful event or experience.

In a study published in the journal Social Psychiatry and Psychiatric Epidemiology, researchers identified the following specific risk factors for psychotic depression:

• Living alone, without a partner or roommates

• Having limited contact with friends and/or family

• Having few or no close confidants or trusted friends

• Previous experience of adversity during childhood

• Having a family history of mental illness

• Having more neurological soft signs (NSS)

Certain factors, such as sleep deprivation, prescription drug abuse and misuse of cannabis and other substances are less closely linked to depression, but are associated with an elevated risk of developing psychosis.

Like other forms of depression, psychotic depression can potentially occur in people of all ages and backgrounds. 

Because psychotic depression is often severe in nature, it’s important to seek help if you think you may be affected. 

Unlike more mild forms of depression, psychotic depression rarely improves on its own. If you have a combination of depression and psychosis symptoms, it’s important to seek help from a licensed mental health provider as soon as you can.

You can do this by asking your primary care provider for a mental health referral, contacting a psychiatrist in your location or from home using our online psychiatry services.

Diagnosing Psychotic Depression

Psychotic depression is a serious mental illness, but it’s not always easy to diagnose. In fact, a study published in the Journal of Clinical Psychiatry in 2008 noted that many signs of psychotic depression are missed in clinical settings.

To make an accurate diagnosis, your mental health provider may ask you about your symptoms and personal mental health history. You may be asked to provide information about:

• Voices you hear or things you see that other people don’t notice or believe in

• Any beliefs, concerns or thoughts that affect your wellbeing on a frequent basis

• Your relationships with friends, family and other people who can provide support

• Any previous experiences with depression or other mental disorders

• Your physical health history, including any disease or preexisting conditions

• Your family’s history of physical or mental health issues, if appropriate

Your mental health provider may use the Psychotic Depression Assessment Scale (PDAS) or a similar rating scale to assess your symptoms.

In some cases, you may be asked by your provider to provide a blood sample, urine sample or undergo a brain scan. These tests are used to rule out other medical conditions that can cause similar symptoms to psychotic depression.

Antidepressants and Antipsychotic Medications

If you’ve been diagnosed with major depression with psychotic features, you’ll usually receive a prescription for medication to control your symptoms. 

Psychotic depression is generally treated with antidepressants (medications that enhance your mood and treat some symptoms of depression) and antipsychotics (medications for controlling delusions and hallucinations) — these are both considered first-line treatments.

Research suggests that a combination of antidepressants and antipsychotics is generally more effective than antidepressant or antipsychotic monotherapy (depression treatment with one medication).

Unlike other types of depression, psychotic depression rarely improves without medication. In fact, in early studies of treatments for psychotic depression, the response to placebo treatments was close to zero percent.

Make sure to take your medications exactly as prescribed. While antipsychotic medications are often only taken for a short period of time, you may need to use antidepressants for a period of several months or longer to prevent your depression from returning.

Electroconvulsive Therapy

When medication alone isn’t enough to treat psychotic depression, your mental health provider may recommend electroconvulsive therapy (ECT).

This type of treatment involves using an electric current to modify your brain activity. It’s done in a hospital setting under general anesthesia, meaning you’ll be asleep for the procedure and won’t feel any pain. 

Although electroconvulsive therapy is a safe and effective treatment for most people, it has the potential to cause side effects. Adverse effects of ECT may include:

• Headaches

• Nausea

• Memory loss

• Confusion that occurs following treatment

• Changes in blood pressure, such as hypotension (low blood pressure) and hypertension (high blood pressure)

• Tachycardia (rapid heartbeat) and/or other cardiovascular health issues

• Muscle soreness

ECT is usually performed once or several times per week for six to 12 sessions. You may need to take part in additional sessions if your symptoms don’t improve over time.

Psychotherapy

Psychotherapy, or talk therapy, is a common treatment for nonpsychotic depression. However, research suggests that psychotherapy is less effective at improving the symptoms of depression when psychotic symptoms are also present.

Your mental health provider may recommend cognitive behavioral therapy (CBT) or other forms of therapy in combination with antidepressant and antipsychotic medication. 

Inpatient Mental Health Treatment

If your psychotic depression involves severe symptoms that affect your safety and/or wellbeing, you may need to receive inpatient care (treatment that involves staying in a hospital).

Inpatient treatment in a hospital or medical center may be recommended if you display signs of suicidal ideation or behavior, or if your severity of depression is extreme. 

Because psychotic depression is a severe mental health condition, people experiencing it often fail to seek professional help by themselves. 

If you have a family member, close friend or other loved one who displays the signs of psychotic depression, you can help them by:

• Listening and trying to understand how they feel. If possible, try to talk to the person about how they feel. Let them discuss their thoughts and feelings with you and ask them if they’d like you to help them receive care from someone who can help.

• Connecting them with a mental health provider. Psychotic depression is treatable. If you’re worried about someone who displays signs of psychotic depression, you can help them by introducing them to a mental health professional.You can help someone to receive mental health treatment by contacting a local mental health center or using our online psychiatry service.

• Preparing an emergency plan. People with psychotic depression have a significant risk of self-harm or suicide, making it important to have a plan ready ahead of time for mental health emergencies. Our guide to what to do in a mental health crisis lists actionable, effective steps that you can take to make sure you’re prepared for a mental health emergency.

• Helping them as they recover. Many people with psychotic depression are able to fully recover with antipsychotic and antidepressant medication. Be supportive and try to help if a friend or loved one is making an active effort to recover. 

Psychotic depression is a severe form of mental illness that almost always requires professional treatment. 

With the right combination of first-line treatments and ongoing care, many people affected by psychotic depression are able to overcome their depressive symptoms and fully recover. 

If you’re worried that you may have psychotic depression, you can access help by reaching out to your primary care provider, scheduling an appointment with a psychiatrist or using our online mental health services to get help from home.

You can also learn more about dealing with depression and other mental illnesses with our free online mental health resources.