Psychotic Depression

Psychotic depression is a subtype of major depression that occurs when a severe depressive illness includes some form of psychosis. The psychosis could be hallucinations (such as hearing a voice telling you that you are no good or worthless), delusions (such as, intense feelings of worthlessness, failure, or having committed a sin) or some other break with reality. Psychotic depression affects roughly one out of every four people admitted to the hospital for depression.

According to the National Institute of Mental Health, a person who is psychotic is out of touch with reality. People with psychosis may hear “voices.” Or they may have strange and illogical ideas. For example, they may think that others can hear their thoughts or are trying to harm them. Or they might think they are possessed by the devil or are wanted by the police for having committed a crime that they really did not commit.

People with psychotic depression may get angry for no apparent reason. Or they may spend a lot of time by themselves or in bed, sleeping during the day and staying awake at night. A person with psychotic depression may neglect appearance by not bathing or changing clothes. Or that person may be hard to talk to. Perhaps he or she barely talks or else says things that make no sense.

People with other mental illnesses, such as schizophrenia, also experience psychosis. But those with psychotic depression usually have delusions or hallucinations that are consistent with themes about depression (such as worthlessness or failure), whereas psychotic symptoms in schizophrenia are more often bizarre or implausible and have no obvious connection to a mood state (for example, thinking strangers are following them for no reason other than to harass them). People with psychotic depression also may be humiliated or ashamed of the thoughts and try to hide them. Doing so makes this type of depression very difficult to diagnose.

But diagnosis is important. Its treatment is different than for nonpsychotic depression. Also, having one episode of psychotic depression increases the chance of bipolar disorder with recurring episodes of psychotic depression, mania, and even suicide.

Common symptoms for patients who have psychotic depression include:

Usually, treatment for psychotic depression is given in a hospital setting. That way, the patient has close monitoring by mental health professionals. Different medications are used to stabilize the person’s mood, typically including combinations of antidepressants and antipsychotic medications.

Antipsychotic drugs affect neurotransmitters that allow communication between nerve cells in areas of the brain that regulate our ability to perceive and organize information about the world around us. There are a number of antipsychotic, or neuroleptic, medications commonly used today. These include risperidone, olanzapine, quetiapine, aripiprazole, cariprazine, and asenapine. Each drug has unique side effects and may differ in its clinical efficacy profile. Usually, though, these drugs are better tolerated than earlier antipsychotics.

Treatment for psychotic depression is very effective. People are able to recover, usually within several months. But continual medical follow-up may be necessary. If the medications do not work to end the psychosis and depression, sometimes electroconvulsive therapy (ECT) is used. It’s important for the patient to work with the doctor to find the most effective drugs with the least side effects. Because psychotic depression is quite serious, the risk of suicide is also great.

SOURCES:

National Institute of Mental Health: “What is Depression?”

National Institute of Mental Health: “What are the Different Forms of Depression?”

National Institute of Mental Health: “Medications.”

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5.

Fieve, R. Bipolar II, Rodale Books, 2006.

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Psychotic Depression

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