What Is Psychotic Depression?

Psychotic depression is a subtype of major depressive disorder (MDD). It is also referred to as MDD with psychotic features.

Psychotic depression symptoms are the same as those of MDD, such as feeling sad, listlessness, and having sleep problems, but they also include symptoms of psychosis. The hallmark symptoms of psychosis are hallucinations and delusions.

This article will discuss the symptoms, causes, and treatment of psychotic depression.

Definition of Psychosis

Psychosis is not a condition in and of itself, but rather a symptom or an experience.

Psychosis refers to the experience of losing touch with reality. This primarily happens in two ways:

• Hallucinations: Sensory experiences not based in reality, such as seeing, hearing, tasting, feeling (through touch), or smelling things that are not really there and that others cannot sense.
• Delusions: Persistent false beliefs that are not grounded in reality, such as paranoia, a sense that someone is trying to harm you.

A person experiencing psychosis can have either hallucinations or delusions, or a combination of both.

Symptoms of psychosis (sometimes described as a psychotic episode) are generally part of a bigger condition such as schizophrenia, depression, or Parkinson's disease.

Psychosis can also occur with certain medications, substance use, or other health problems.

Depression with Psychotic Features

In the past, the term "psychosis" was used to describe severity in terms of depression. It indicated that a person with depression was severely mentally impaired and could not adapt to the demands of daily life. Hallucinations or delusions were not part of the diagnosis.

The "Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition" (DSM–5) is the handbook used by clinicians to assess and diagnose mental health disorders. It considers psychotic depression to be a subtype of major depressive disorder when symptoms of psychosis are present. Unlike in the previous version, the DSM-4, severity of depression is not a factor in the diagnosis of psychotic depression.

Psychotic depression affects approximately four out of 1,000 people in the general population. This rate increases with age, affecting between 14 and 30 people out of 1,000 who are more than 60 years old. The rates of psychotic depression are significantly higher in people with MDD.

Symptoms

Symptoms of MDD can vary from person to person and range from mild to severe. For a diagnosis of MDD, symptoms must last at least two weeks and must represent a change in the person's prior level of functioning.

They may include:

• Persistent feelings of sadness or hopelessness
• Feeling worthless or guilty
• Loss of interest or pleasure in activities the person once enjoyed
• Being easily irritated or frustrated
• Physical problems, such as headache, stomachache, aches and pains, or sexual dysfunction
• Changes in appetite (may lead to weight loss or weight gain)
• Sleep changes such as sleeping too much or too little
• Low energy or fatigue
• Restlessness or an increase in purposeless movement, such as difficulty sitting still, pacing, or wringing hands
• Slowed movement or speech
• Difficulty thinking, concentrating, or making decisions
• Self-harm
• Thoughts of death or suicide

A person experiencing psychotic depression has the classic symptoms of MDD and also has hallucinations and/or delusions.

People with psychotic depression are at an increased risk of self-harm and of suicidal thoughts and actions.

Early intervention is important to help keep a person with psychotic depression safe. If you or someone you know is showing symptoms of psychotic depression, seek an evaluation with a healthcare provider or mental health specialist right away.

Psychosis Without Depression

Psychosis can occur without mood disorders such as depression.

Other disorders that may involve psychosis include:

• Schizophrenia
• Bipolar disorder
• Schizoaffective disorder
• Substance-induced psychosis (including withdrawal from drugs or alcohol)
• Postpartum psychosis
• Delusional disorder
• Brief psychotic disorder
• Schizophreniform disorder

Psychosis is commonly associated with schizophrenia, but psychotic depression and schizophrenia are different conditions with distinct diagnostic criteria and treatments.

Causes

It isn't known exactly what causes depression, including what causes psychotic depression. Research into depression has led scientists to believe it is caused by a combination of genetic, biological, environmental, and psychological factors.

Depression is incredibly multifaceted and can affect anyone. This makes it difficult to pinpoint exact causes of MDD.

Instead, research focuses on correlations instead of causation. While researchers haven't pinpointed whether these risk factors cause depression, they do note that there are commonalities among people who have depression.

Right now, the risk factors for MDD are applied as risk factors for psychotic depression. This may change as psychotic depression is studied further.

Risk Factors 

Risk factors for depression include:

• Brain chemistry: Changes and abnormalities in the brain and brain chemistry, such as the levels of neurotransmitters.
• Genetics: Having a family member with depression.
• Childhood trauma: Including abuse or neglect.
• Life events: Including stress, the death of a loved one, upsetting events, isolation, and lack of support.
• Medical conditions: Serious health conditions, such as cancer and heart disease, as well as chronic pain or illness.
• Medication: Side effects of medications, recreational drugs, and alcohol.
• Personality: Characteristics such as being easily overwhelmed or having difficulties coping.

A four-year longitudinal study suggested other risk factors for MDD might include:

• Being a younger adult
• Being female
• Being widowed, separated, or divorced
• Having a low socioeconomic status
• Having a lower education level
• Living in areas with a high unemployment rate

Diagnosis

To be diagnosed with psychotic depression, a person must first meet the following criteria for MDD set out by the DSM-5:

1. Depressed mood most of the day, nearly every day, as indicated by self-reporting (feeling sad, empty, hopeless, etc.) or observations made by others.
2. Noticeable decrease in interest or pleasure in all, or almost all, activities nearly every day.
3. Significant weight loss or weight gain without trying to lose or gain weight, or a decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia (excessive sleep) nearly every day.
5. Psychomotor agitation (restlessness, inability to stay still, wringing hands, etc.) or psychomotor retardation (a slowing down of thoughts and physical motion) nearly every day.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate or being indecisive nearly every day.
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide.

These symptoms must not be caused by another condition or more plausible explanation.

If the criteria for MDD are met, and the person is experiencing hallucinations and/or delusions at the same time as the MDD episodes, a diagnosis of psychotic depression can be made.

Labs and Tests

There are a number of diagnostic tools a healthcare professional may use to make a diagnosis of psychotic depression.

History and Physical Exam

During an initial appointment, a healthcare professional will take a thorough history and may do a physical exam to get a picture of overall health and to discuss current concerns. This may involve:

• Getting a medical history (including mental health and substance use)
• Getting a family history (including mental health and substance use)
• A discussion of symptoms in detail
• Listening to the heart
• Checking reflexes

Laboratory Tests

While there are no lab tests for depression, urine samples, blood tests, or other lab tests may be run to check for other conditions that could be causing the symptoms, or to get an idea of overall health.

Rating Scales

Some healthcare providers might administer questions from a rating scale such as the Clinical Interview for Depression or the Hamilton Rating Scale for Depression (HAM-D).

A 2013 study found that using a combination of rating scales and screening tools may be more helpful for diagnosing psychotic depression than depression scales alone.

Misdiagnosis 

Psychotic depression is often misdiagnosed. In a study by the National Institute of Mental Health (NIMH), 27% of the sample of patients with a diagnosis of psychotic depression were initially incorrectly diagnosed. The number of people in the general population with psychotic depression who have been misdiagnosed is estimated to be even higher.

In the study, psychotic depression was most commonly misdiagnosed as a different mood disorder.

People with MDD often don't report psychotic symptoms or they minimize them. Some reasons for this may include:

• They don't think that they or their symptoms are abnormal.
• They don't want to be considered ill.
• They want to be left alone.
• They may not recall psychotic symptoms they experience in one mental state, such as when they are manic, at a time when they are in another state like depresson.
• They may not think abstractly enough to answer broad general questions such as, "Do you see things or hear things?" or whether they feel persecuted. Asking about specific hallucinations and delusions often works better.

Healthcare providers and loved ones of people with MDD should not assume that psychotic symptoms are not present just because the person hasn't mentioned them. Further investigation may be needed.

Treatment

It is rare for psychotic depression to resolve without treatment.

Treatment for psychotic depression typically involves medication and/or electroconvulsive therapy (ECT), electrical stimulation of the brain.

Lifestyle

While unlikely to be effective treatments for psychotic depression on their own, some lifestyle changes can help with symptom management, treatment support, and quality of life. These might include:

• Regular exercise
• Getting enough quality sleep on a regular basis
• Eating a healthy diet
• Avoiding alcohol
• Having a strong support system

Talk Therapies

Psychotherapy (talk therapy) on its own has not been shown to be effective at treating psychotic depression. It is sometimes used in combination with other types of therapies and medications.

Some new psychotherapies are showing promise for treating psychotic depression.

Electroconvulsive Therapy (ECT)

ECT is a procedure in which a seizure is induced through a brief application of electric current to the brain through the scalp. It is performed under general anesthesia.

ECT is considered a safe and effective treatment for psychotic depression. It may be more effective than medication, and it is recommended as a first-line treatment in many guidelines because of its quick results.

ECT has been shown to be very effective in reducing suicidal ideation, or intent, in people with MDD who had previously expressed such thoughts.

While ECT often provides quick relief, on-going treatment (such as with medication) is often needed for lasting results.

Prescriptions

A combination of an antipsychotic and an antidepressant medication is usually more effective for treating psychotic depression than treatment with either medication alone.

Antipsychotic medications that may be prescribed include:

• Zyprexa (olanzapine)
• Seroquel (quetiapine)
• Risperdal (risperidone)

Antidepressants that may be prescribed include the following types:

Selective serotonin reuptake inhibitors (SSRIs)

• Zoloft (sertraline)
• Paxil (paroxetine)
• Prozac (fluoxetine)
• Celexa (citalopram)

Serotonin and noradrenaline reuptake inhibitors (SNRIs)

• Effexor (venlafaxine)
• Pristiq (desvenlafaxine)
• Cymbalta (duloxetine)

N-Methyl-D-Aspartate (NMDA) receptor antagonists

• Auvelity (dextromethorphan and bupropion)

These medications can come with potential side effects and risks.

People with psychotic depression and their healthcare providers need to weigh the benefits against the risks of medications and their combinations.

It may take up to eight weeks to see a response to these medications with psychotic depression. In cases where immediate help is needed, ECT is often offered instead of, before, or along with medication.

Coping

While undergoing treatment for psychotic depression, there are ways to help cope with symptoms and improve general quality of life.

• Practice mindfulness and relaxation: Yoga, breathing exercises, tai chi, meditation, and other relaxation exercises can help reduce stress.
• Engage in activities you enjoy: Find a hobby, meet with friends, go to the movies, or do anything that brings you joy.
• Learn to recognize your triggers: Keeping a diary and speaking to friends and family may help you learn what is happening before and during psychotic episodes. Seeing patterns can help you manage or avoid your triggers and seek help before you are able to.
• Develop and maintain healthy habits: Regular exercise, a healthy diet, and getting enough sleep can go a long way to help you manage psychotic depression symptoms and feel well overall.
• Get outside: Whether on a hike in the great outdoors or sitting on your porch, spending time outside can be a mood lifter.
• Avoid recreational drugs and alcohol: These can make psychotic depression symptoms worse and can interfere with medications.
• Create a crisis plan: Plan and write down what you need when you are in crisis in case you are unable to tell others in the moment.
• Set realistic goals: Smaller, attainable goals can be motivating and add up to bigger positive changes.

Frequently Asked Questions 

How does psychotic depression differ from schizophrenia?

Schizophrenia is a psychotic disorder, while psychotic depression is a mood disorder.

Schizophrenia is a stand-alone condition, while psychotic depression is a subtype of major depressive disorder.

While both conditions result in psychotic symptoms, such as hallucinations and/or delusions, with psychotic depression these psychotic symptoms happen at the same time as major depressive episodes.

Is psychotic depression manageable?

Psychotic depression is often debilitating for the people experiencing it and those around them. Thankfully, treatment is available, such as medications and/or electroconvulsive therapy.

How do you know if you’re having a nervous breakdown?

"Nervous breakdown" is not a medical term, but it is often used colloquially to mean intense mental and emotional distress.

In terms of major depressive disorder, symptoms of psychosis, including hallucinations and delusions, can occur. When this happens, it is called MDD with psychotic features, or psychotic depression. 

Are you disabled if you have psychotic depression?

Major depressive disorder, under which psychotic depression falls, is considered a disability by the Americans with Disabilities Act (ADA).

A person with psychotic depression must be given reasonable accommodations, including a flexible work schedule, and is offered protection against discrimination, such as with employment or housing.

A Word From Verywell

Psychotic depression can be intrusive and scary, greatly affecting a person's ability to function and their relationships with others. Thankfully, treatments are available to help manage symptoms and often achieve remission.

If you or a loved one are experiencing symptoms of psychotic depression, make an appointment with a healthcare provider or mental health specialist to discuss a diagnosis and make a treatment plan.