Psychotic Depression – What is it?

Psychotic depression refers to cases of clinical depression that have psychotic features. People who have depression with psychotic features experience hallucinations and/or delusions, alongside typical symptoms of depression ^[1]. Psychotic depression is often treated with a combination of therapy and antipsychotic and antidepressant medications ^[2].

What is psychotic depression?

Psychotic depression is when a person with a depressive disorder, such as major depressive disorder or persistent depressive disorder, also experiences symptoms of psychosis.

Major depressive disorder is a mental health condition listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). One of the specifiers for major depressive disorder indicates that it can occur “with psychotic features” ^[1]. Meanwhile, persistent depressive disorder is a less severe, but long-lasting, form of depression. Psychotic depression refers to a case of depression that involves psychotic features.

More specifically, a person with psychotic depression will have common symptoms of depression, as well as hallucinations and/or delusions. Delusions are fixed beliefs that a person maintains, even when the belief is clearly untrue, or they have evidence that disproves the belief. Persecutory delusions, in which a person believes someone is trying to harm them, are common. Hallucinations involve hearing, seeing, tasting, smelling, or feeling something that is not actually present in the environment ^[3].

Someone with psychotic depression will experience depressive symptoms like low mood, loss of interest in usual activities, difficulty with concentration, and feelings of fatigue, as well as symptoms of hallucinations and/or delusions ^[1].

Symptoms of psychotic depression

Symptoms of psychotic depression include both symptoms of depressive disorders and symptoms of psychosis. These symptoms are described in more detail below.

Depression Symptoms

Symptoms of depression include, but aren’t limited to ^[4]:

• Ongoing feelings of sadness or emptiness
• Feelings of hopelessness
• Feeling guilty or worthless
• Losing interest in most activities or lack of pleasure with enjoyable activities
• Reduced energy levels or extreme fatigue
• Having a problem concentrating or making important decisions
• Changes in sleep habits, which can involve either sleeping too much or sleeping too little
• Appetite disturbances, which can include eating too much or eating too little, leading to either weight gain or weight loss
• Suicidal ideation, or suicide attempts
• Changes in movement patterns, which can include either restlessness or slowed movements

Symptoms of Psychosis

Psychotic symptoms that occur with depression include, but aren’t limited to ^[3]:

• Delusions, which are false beliefs that a person maintains, even when there is evidence of the inaccuracy of the belief. This could include believing that the CIA is monitoring you or believing that someone or something is trying to harm you.
• Hallucinations, which involve the perception of sensations that are not actually present in the environment. For example, someone experiencing hallucinations may believe that they are seeing, hearing, feeling, tasting, or smelling things that are not present. Auditory hallucinations, in which a person hears voices, are the most common.

Causes of psychotic depression

There is not one single cause of psychotic depression, but rather a combination of factors that increase the risk of developing the condition. Risk factors for psychotic depression may include ^[5]:

• Lack of social support (living alone, having no close friends, lack of contact with friends and family)
• Neurological problems
• History of child abuse/neglect or other adverse childhood experiences
• Genetics (based upon the fact that family history of mental illness and psychosis are both linked to psychotic depression)

Diagnosing psychotic depression

Psychotic depression is diagnosed using the DSM-5. First, a patient must meet diagnostic criteria for major depressive disorder or persistent depressive disorder. A doctor or mental health professional will determine if a diagnosis is warranted after taking a complete medical history, gathering information about the patient’s social functioning, and asking about any current or recent stressors. A professional diagnosing psychotic depression may use standardized instruments to determine if depression symptoms are present.

To be diagnosed with major depressive disorder, a patient must meet the following diagnostic criteria ^[1]:

• Demonstrate five or more symptoms of depression, which are present every day for at least two weeks
• One of the five symptoms must be either depressed mood or loss of interest/pleasure with regular activities.
• The mood disturbance that occurs with depression must reflect a change from a person’s previous level of functioning.
• Depression symptoms cause significant distress or difficulty with functioning in important areas of daily life, such as work or school.

To be diagnosed with persistent depressive disorder, a patient must meet the following criteria ^[1]:

• Show symptoms of depression for most of the day on most days for at least two years.
• Have not had an absence of symptoms for more than two months at a time during those two years.
• The presence of two or more of the following symptoms during periods of depression: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration and decision making, and feelings of hopelessness.  

A depressive disorder with psychotic features diagnosis requires that a patient also show symptoms of hallucinations or delusions. When making a diagnosis, a clinician will list “with psychotic features” as a specifier. This specifier can occur one of two ways ^[1]:

• With mood-congruent psychotic features: This specifier is used when hallucinations or delusions all center on depressive themes, such as guilt, death, or inadequacy.
• With mood-incongruent psychotic features: This specifier is used when a person’s hallucinations and delusions do not center on depressive themes, such as guilt, death, or inadequacy.

Treatment for psychotic depression

Depression is typically treated with medication, talk therapy, or both ^[4]; however, treating psychotic depression may require specialized methods. The most commonly recommended treatment modalities for psychotic depression are medication and talk therapy, which are described in more detail below. Patients also benefit from psychosocial therapy ^[2].

Medication for Psychotic Depression

Patients with psychotic depression typically do best taking a combination of medications that includes an antidepressant treatment and an antipsychotic medicine. The combination of these two medications is more effective than either medication on its own ^[2].

Some specific medication combinations that may be effective include ^[2]:

• Venlafaxine and Quetiapine
• Sertraline and Olanzapine
• Fluoxetine and Olanzapine
• Amitriptyline and Perphenazine

After a patient is stabilized on an antipsychotic medication for several months, they may be able to gradually taper off of it. However, patients with psychotic depression have a greater relapse risk when compared to patients who have depression without psychotic features, so it’s important to consult with your doctor before discontinuing any medication ^[2].

ECT for Psychotic Depression

Electroconvulsive therapy (ECT) is also beneficial for treating psychotic depression ^[2]. This form of treatment uses electrical impulses to stimulate the brain while a patient is under anesthesia. It may cause temporary side effects, such as confusion and memory loss ^[4].

Therapy for Psychotic Depression

Therapy methods have not been as well-studied in the treatment for depression with psychosis when compared to treatment of depression without psychotic features. Nonetheless, therapy is considered a necessary component of treatment ^[2].

The following therapies may be beneficial for patients with psychotic depression ^[2]:

• Acceptance and Commitment Therapy (ACT): ACT can benefit patients with psychotic depression by teaching them skills like mindfulness and flexible thinking.
• Behavioral Activation: This therapy can help patients to change dysfunctional behaviors.

Frequently asked questions about psychotic depression

The answers to the following frequently-asked questions provide additional information about psychotic depression.

What is the difference between psychotic depression and major depression?

Psychotic features is a diagnostic specifier for major depressive disorder. is a form of major depression. Major depression is a general diagnosis in which a person experiences symptoms of depression for at least two weeks. Psychotic depression is a specifier applied to a particular form of major depression in which patients experience hallucinations and/or delusions ^[1].

What is the difference between psychotic depression and schizophrenia?

Patients with schizophrenia experience symptoms of psychosis, including hallucinations and delusions, but schizophrenia is different from depression with psychotic features. Patients with depression experience other symptoms beyond hallucinations and delusions, including depressed mood, loss of interest in activities, fatigue, and suicidal ideation. These depressive symptoms are absent in schizophrenia.

What is the outlook for people with psychotic depression?

With effective treatment, people who live with psychotic depression can learn to overcome the effects of their symptoms and lead healthy, fulfilling lives. However, psychotic depression is associated with a higher risk of relapse when compared to depression without psychotic features ^[2], so it’s important to stay engaged in treatment.

Treatment for psychotic depression is effective, but studies suggest that this form of depression seems to be more severe when compared to depression without psychotic features. With psychotic depression, depressive episodes last longer and more likely to reoccur ^[6].