Psychotic Depression

Psychotic depression, also known as depressive psychosis, is a condition characterized by having a major depressive disorder with psychotic features. Psychotic features can include delusions, hallucinations, or paranoia.

What Is Psychotic Depression (PD)?

Psychotic Depression is a condition where a person has severe clinical depression with psychotic episodes. The symptoms of psychosis include hallucinations and delusional thinking. Major depression affects mood, behavior, and other functions such as sleep and appetite. A 2015 study [mfn] Gaebel, W., & Zielasek, J. (2015). Focus on psychosis. Dialogues in clinical neuroscience, 17(1), 9–18. https://doi.org/10.31887/DCNS.2015.17.1/wgaebel [/mfn] found that psychosis refers to when a person feels disconnected from reality. It usually occurs when an individual experiences things that are not real such as hallucinations or delusions. This condition occurs when a person experiences major depression along with psychotic episodes.

A 2013 study [mfn] Rothschild A. J. (2013). Challenges in the treatment of major depressive disorder with psychotic features. Schizophrenia bulletin, 39(4), 787–796. https://doi.org/10.1093/schbul/sbt046 [/mfn] defined PD as a “serious illness during which a person suffers from the combination of depressed mood and psychosis, with the psychosis, commonly manifesting itself as a nihilistic type delusion, with the belief that bad things are about to happen.” People with this condition often see or hear things that are not real and experience psychotic episodes only during major depressive episodes. Hence, it is important to seek medical attention since it increases the chances of suicide among patients [mfn] Zalpuri, I., & Rothschild, A. J. (2016). Does psychosis increase the risk of suicide in patients with major depression? A systematic review. Journal of affective disorders, 198, 23–31. https://doi.org/10.1016/j.jad.2016.03.035 [/mfn] . It also makes the patient believe in false perceptions and beliefs and paranoia.

Delusions can be defined as a reinforced misrepresentation of events. Delusions can be classified as mood-congruent or incongruent. Common themes of mood-congruent delusions include –

• Personal inadequacy
• Guilt
• Persecution
• Disease
• Punishment

A delusion is a false belief and clearly indicates an abnormality in the affected person’s content of thought. A person with a delusion will firmly hold their belief regardless of evidence that proves the contrary. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM 5) lists psychotic features as a “subset of major depression.” However psychotic features are not indicators of the severity of major depression in the DSM 5.

Understanding Psychotic Depression

Individuals with this condition experience the symptoms of a major depressive episode along with one or more psychotic symptoms. Research [mfn] Rothschild A. J. (1996). Management of psychotic, treatment-resistant depression. The Psychiatric clinics of North America, 19(2), 237–252. https://doi.org/10.1016/s0193-953x(05)70286-0 [/mfn] suggests that patients with psychotic depression are likely to be under-identified in routine practice settings, as psychotic symptoms can be more subtle in mood disorders. It is also found that patients are more reluctant to disclose the symptoms because of paranoia or embarrassment. Some people are found to develop false beliefs about their health.

For instance, believing that they have cancer when they actually don’t. Others sometimes hear voices that say “you are not good enough” or “you should die”. These delusions or hallucinations seem real to the people who are experiencing this condition. This also includes hearing, smelling, or believing things that don’t exist or aren’t real. This can be dangerous since these delusions can make people suicidal. The best way to cope with the symptoms of depression and psychosis is to consult a doctor. It is of utmost importance to stick to the treatment plan to prevent any future relapse.

According to a 1991 study [mfn] Johnson, J., Horwath, E., & Weissman, M. M. (1991). The validity of major depression with psychotic features based on a community study. Archives of general psychiatry, 48(12), 1075–1081. https://doi.org/10.1001/archpsyc.1991.01810360039006 [/mfn] , an estimated 15% to 19% of patients with major depression exhibit hallucinations or delusions. A study [mfn] Arrasate, M., González-Ortega, I., García-Alocén, A., Alberich, S., Zorrilla, I., & González-Pinto, A. (2016). Prognostic value of affective symptoms in first-admission psychotic patients. International Journal of Molecular Sciences, 17(7), 1039. https://doi.org/10.3390/ijms17071039 [/mfn] found that 86% of people with first-episode psychotic depression achieve syndromal recovery but only 35 percent recovered functionally.

Out of these, a large percentage of individuals (47%) had their diagnosis changed to bipolar disorder or schizoaffective disorder. Reports suggest that 14.7 percent to 18.5 percent of people with major depression also experience psychotic features and that the prevalence rates may rise with age. A review found delusions occur without hallucinations in about one half to two-thirds of the patients with this disorder.

Experts suggested that psychotic depression still requires further research. The combination of medication and Electroconvulsive Theory (ECT) has shown to be effective. However, research is required to establish how long antipsychotic medications need to be taken.

Signs And Symptoms Of Psychotic Depression

The signs and symptoms of PD are a combination of severe depression with psychotic features. They are as follows:

1. Symptoms of severe depression

Individuals with this disorder have symptoms of major depression along with psychosis. The signs and symptoms of this condition are as follows:

• Fatigue
• Irritability
• Difficulty concentrating
• Feelings of hopelessness or helplessness
• Feelings of worthlessness
• Social isolation
• Loss of interest in activities that were once enjoyable
• Sleeping too little or too much
• Changes in appetite
• Sudden weight gain or weight loss
• Talks or threats to suicide

2. Symptoms of psychosis

Psychosis symptoms are characterized by a lack of contact with reality. The symptoms include delusions, or false beliefs and false perceptions, hallucinations, seeing or hearing things that are not there. The symptoms of psychotic episodes associated with major depression include:

• Delusions: Thoughts or beliefs that are untrue
• Hallucinations: Hearing, feeling, smelling, seeing, or tasting things that are not there
• Psychomotor agitation: Not being able to relax or sit still, and constantly fidgeting
• Psychomotor retardation: This occurs when both their thoughts and physical movements are slowed down
• Having suicidal thoughts

Relationship Between Psychotic Depression And Bipolar Disorder

It is still under investigation to understand whether there is a relationship between psychotic depression and bipolar disorder. Several studies [mfn] Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic advances in psychopharmacology, 8(9), 251–269. https://doi.org/10.1177/2045125318769235 [/mfn] found that patients with this disorder with an early age of onset have a higher risk of developing bipolar disorder than nonpsychotic depressed patients of subsequently developing bipolar disorder.

In addition to this, people who are related to patients with psychotic depression also may have a higher prevalence of bipolar disorder as compared to nonpsychotic depressed patients. Depressed relatives with bipolar disorder are more likely to suffer from the psychotic subtype when compared with depressed relatives of healthy controls.

Studies [mfn] Ostergaard, S. D., Waltoft, B. L., Mortensen, P. B., & Mors, O. (2013). Environmental and familial risk factors for psychotic and non-psychotic severe depression. Journal of affective disorders, 147(1-3), 232–240. https://doi.org/10.1016/j.jad.2012.11.009 [/mfn] suggest that a parental history of bipolar disorder is a possible risk factor for psychotic depression but not for nonpsychotic depression. A 2007 study [mfn] Goes, F. S., Sadler, B., Toolan, J., Zamoiski, R. D., Mondimore, F. M., Mackinnon, D. F., Schweizer, B., Bipolar Disorder Phenome Group, Raymond Depaulo, J., Jr, & Potash, J. B. (2007). Psychotic features in bipolar and unipolar depression. Bipolar disorders, 9(8), 901–906. https://doi.org/10.1111/j.1399-5618.2007.00460.x [/mfn] found that psychotic features during a depressive episode increased the likelihood of bipolar disorder diagnosis.

The findings suggested that disorganization, depressive episodes, and psychotic symptoms during the first manic episode are salient features in the onset of bipolar disorder. Another 2008 study [mfn] Tillman, R., Geller, B., Klages, T., Corrigan, M., Bolhofner, K., & Zimerman, B. (2008). Psychotic phenomena in 257 young children and adolescents with bipolar I disorder: delusions and hallucinations (benign and pathological). Bipolar disorders, 10(1), 45–55. https://doi.org/10.1111/j.1399-5618.2008.00480.x [/mfn] also found that the manifestation of bipolar disorder with psychotic symptoms had been related to poorer long-term outcomes, hospitalizations, lower episodic functioning, and a lower clinical recovery rate.

Read More About Bipolar Disorder Here

Psychotic Depression Vs Schizophrenia

The psychotic symptoms of major depressive disorder with psychotic features are episodic and occur only during an episode of major depression. A 2010 study [mfn] Craddock, N., & Owen, M. J. (2010). The Kraepelinian dichotomy – going, going… but still not gone. The British journal of psychiatry : the journal of mental science, 196(2), 92–95. https://doi.org/10.1192/bjp.bp.109.073429 [/mfn] pointed out that mood disorder symptoms in schizophrenia may be a good prognostic indicator. Patients with schizophrenia display psychotic symptoms that occur in the absence of any mood disorder. Studies [mfn] Ostergaard, S. D., Waltoft, B. L., Mortensen, P. B., & Mors, O. (2013). Environmental and familial risk factors for psychotic and non-psychotic severe depression. Journal of affective disorders, 147(1-3), 232–240. https://doi.org/10.1016/j.jad.2012.11.009 [/mfn] show that a family history of schizophrenia is not associated with an increased risk of psychotic depression.

Patients with this disorder and schizophrenia differ in the hypothalamic pituitary adrenal axis activity and all-night sleep electroencephalogram readings. Those with PD usually experience psychotic episodes based on the theme of depression such as worthlessness or failure. In the case of patients with schizophrenia, the psychotic episodes are bizarre or implausible and generally have no connection to the state of mood. For instance, thinking that strangers are following them even if they aren’t. Evidence [mfn] Upthegrove, R., Birchwood, M., Ross, K., Brunett, K., McCollum, R., & Jones, L. (2010). The evolution of depression and suicidality in first episode psychosis. Acta psychiatrica Scandinavica, 122(3), 211–218. https://doi.org/10.1111/j.1600-0447.2009.01506.x [/mfn] suggests that depression is linked to poorer outcomes in schizophrenia.

Read More About Schizophrenia Here

Causes Of Depressive Psychosis

The exact cause of this condition is still unknown. There is no single cause of this disorder but there are certain triggers that may cause this condition. They are as follows:

1. Environmental Factors

There are several environmental factors that may be a cause of this condition. Stressful life events such as divorce, serious illness, or financial worries can trigger the symptoms of depressive psychosis. A 2013 study found that there was a general overlap in familial and environmental risk factors for PD and non PD.

2. Genetic Factors

Genes may play an important role in developing this condition. Severe depression can run in families. However, it is not known why some people develop psychosis. Genetic factors are suggested to contribute to the disease risk of psychotic depression in partial overlap with disorders along the affective psychotic spectrum.

A 1982 family study [mfn] Gershon, E. S., Hamovit, J., Guroff, J. J., Dibble, E., Leckman, J. F., Sceery, W., Targum, S. D., Nurnberger, J. I., Jr, Goldin, L. R., & Bunney, W. E., Jr (1982). A family study of schizoaffective, bipolar I, bipolar II, unipolar, and normal control probands. Archives of general psychiatry, 39(10), 1157–1167. https://doi.org/10.1001/archpsyc.1982.04290100031006 [/mfn] reported a higher risk of affective disorders including schizoaffective disorder in relatives of probands with the schizoaffective disorder compared with patients with bipolar I, bipolar II, and unipolar depressive disorder. A 1998 twin adoption study [mfn] Lyons, M. J., Eisen, S. A., Goldberg, J., True, W., Lin, N., Meyer, J. M., Toomey, R., Faraone, S. V., Merla-Ramos, M., & Tsuang, M. T. (1998). A registry-based twin study of depression in men. Archives of general psychiatry, 55(5), 468–472. https://doi.org/10.1001/archpsyc.55.5.468 [/mfn] found that severe and psychotic major depression was found to be significantly affected by genetic factors with a heritability of 39%.

3. Traumatic Events

Some people who experience traumatic events such as death or illness are also found to develop this condition. Any adversities experienced during childhood may contribute to this condition. A 2012 study [mfn] Gottlieb, J. D., Mueser, K. T., Rosenberg, S. D., Xie, H., & Wolfe, R. S. (2011). Psychotic depression, posttraumatic stress disorder, and engagement in cognitive-behavioral therapy within an outpatient sample of adults with serious mental illness. Comprehensive psychiatry, 52(1), 41–49. https://doi.org/10.1016/j.comppsych.2010.04.012 [/mfn] found that clinical severity in the psychotic depression with post-traumatic stress disorder group including greater depression, higher levels of suicidal ideation, past suicide attempts, and psychiatric hospitalizations.

Diagnosis Of Psychotic Depression

This disorder is not considered a separate illness. However, it is considered a subtype of major depressive disorder. If an individual is experiencing any symptoms of depression or psychosis, it is important to seek medical attention. The doctor will first assess the patient on the basis of their medical history. He may also refer to the diagnostic criteria laid down by the Diagnostic and Statistical Manual of Mental Disorder (DSM 5).

Healthcare professionals often misdiagnose depression with psychotic features as other disorders. These other illnesses can include schizoaffective disorder, depression not otherwise specified, or mood disorders. A misdiagnosis occurs due to a lack of recognition of the psychotic features of major depression.

In order to be diagnosed with major depressive disorder, a person should have a depressive episode that includes at least five symptoms [mfn] Rothschild, A. J. (2009). Clinical manual for diagnosis and treatment of psychotic depression. ResearchGate. https://www.researchgate.net/publication/233953470_Clinical_Manual_for_Diagnosis_and_Treatment_of_Psychotic_Depression [/mfn] that last at least two weeks. These symptoms include:

• Depressed mood
• Lost of interest in activities
• Insomnia or sleep too much
• Changes in appetite
• Low energy
• Difficulty thinking
• Low levels of concentration
• Agitation or irritability
• Guilt
• Recurrent thoughts of death or suicide

This condition can be diagnosed if the patient is experiencing hallucinations, delusions, or paranoia. This is a very serious condition that requires immediate medical attention. Psychosis increases the risk of suicide significantly in patients which is why it is of utmost importance to pay attention to anyone who is experiencing it.

After analysis, the doctor will arrive at a diagnosis. After the diagnosis of this condition, the doctor will devise a treatment plan that can help to ease the symptoms.

Treatment For Psychotic Depression

There are no treatment methods that can entirely cure this condition. Treatment for this condition usually focuses on managing or reducing the symptoms. However, there are certain accepted treatment methods that involve a combination of medications and therapy that can ease the symptoms.

1. Medications

Some of the medications that are prescribed are antidepressants or Serotonin Reuptake Inhibitors (SSRIs) or Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs). Evidence found that a combination of antidepressants and antipsychotic medications is more effective than either therapy alone or medications alone. The medications that are prescribed are:

• Asenapine (Saphris)
• Cariprazine (Vraylar)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Aripiprazole Abilify)
• Olanzapine (Zyprexa)

However, there may be certain risks associated with medications. A 2020 study found that adding an atypical antipsychotic, especially quetiapine, risperidone, aripiprazole, or olanzapine, to an antidepressant is associated with an increased risk of death. A 2013 study pointed out that it is plausible that if higher doses of fluoxetine had been used, it could have produced greater reductions in depressive symptoms.

2. Electroconvulsive Therapy (ECT)

A 1991 study [mfn] Wilson, K. G., Kraitberg, N. J., Brown, J. H., & Bergman, J. N. (1991). Electroconvulsive therapy in the treatment of depression: the impact on length of stay. Comprehensive psychiatry, 32(4), 345–354. https://doi.org/10.1016/0010-440x(91)90084-p [/mfn] pointed out that electroconvulsive therapy is a highly effective treatment method for people with this condition who don’t respond to traditional medications. It is equally effective as the suggested pharmacological first-line treatment. A 1992 study [mfn] Parker, G., Roy, K., Hadzi-Pavlovic, D., & Pedic, F. (1992). Psychotic (delusional) depression: a meta-analysis of physical treatments. Journal of affective disorders, 24(1), 17–24. https://doi.org/10.1016/0165-0327(92)90056-c [/mfn] found that ECT was significantly more effective than pharmacotherapies.

A 2013 study [mfn] Leadholm, A. K., Rothschild, A. J., Nolen, W. A., Bech, P., Munk-Jørgensen, P., & Ostergaard, S. D. (2013). The treatment of psychotic depression: is there consensus among guidelines and psychiatrists?. Journal of affective disorders, 145(2), 214–220. https://doi.org/10.1016/j.jad.2012.07.036 [/mfn] suggested that this therapy provides rapid relief and is also recommended for those struggling with suicidal thoughts. This electric shock therapy has proven to be safe and effective with psychotic depressive symptoms. It is usually performed by a psychiatrist wherein a carefully controlled electric current through the brain. This creates a mild seizure that impacts the levels of neurotransmitters in the brain. This aims to ease severe depressive and psychotic symptoms. It is typically performed under general anesthesia.

3. Behavioral Activation (BA)

The behavioral activation is used to identify weekly specific goals and work towards meeting those goals. It is designed to increase your contact with positively rewarding activities. It is a customizable and personal treatment plan that is used to treat depressive symptoms. This treatment allows the patient with depression to cope with their negativity.

The goal of behavioral activation is to increase engagement in functional, goal-directed, and valued activities to improve patient contact with environmental positive reinforcement. A 2016 study [mfn] Gaudiano, B. A., Busch, A. M., Wenze, S. J., Nowlan, K., Epstein-Lubow, G., & Miller, I. W. (2015). Acceptance-based Behavior Therapy for Depression With Psychosis: Results From a Pilot Feasibility Randomized Controlled Trial. Journal of psychiatric practice, 21(5), 320–333. https://doi.org/10.1097/PRA.0000000000000092 [/mfn] found that behavioral activation proved to be effective in treating patients with depression.

Recovery From Psychotic Depression

It is a serious and frightening condition but treatment is possible. The prognosis for recovery is good with appropriate treatment. People with this condition tend to recover usually within a few months. Treatment can help ease the symptoms of both depression and psychosis. A combination of medication and ECT can help to manage the severe symptoms of this condition. If you are worried about someone you care about or if you are experiencing any symptoms, it is important to seek medical attention. With little support and therapy, it is possible to manage the symptoms and lead a healthy life.

Psychotic Depression AT A Glance

1. Psychotic depression is having a major depressive disorder with psychotic features.
2. People with this condition often see or hear things that are not real and experience psychotic episodes only during major depressive episodes.
3. This condition can be diagnosed if the patient is experiencing hallucinations, delusions, or paranoia.
4. Bipolar disorder is a possible risk factor for psychotic depression but not for non-psychotic depression.
5. The combination of medication and Electroconvulsive Theory (ECT) has shown to be effective.