National Alliance on Mental Illness
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Psychotic Depression

What is psychotic depression?

“Psychotic depression” is a term used to describe a complex form of depression that is accompanied by psychotic symptoms that can include hallucinations (e.g., “a demon’s voice is telling me that I’m a bad person”), paranoia (e.g., “The FBI wants to capture me because I’m a terrible mother to my children”), or delusions (e.g., “my intestines are rotting inside of me because I deserve to be punished”). Symptoms of psychosis are usually “mood congruent,” meaning that their themes are usually negative and self-deprecating.

Psychotic depression occurs in major depressive disorder or in bipolar disorder. Depression that occurs in schizophrenia or schizoaffective disorder is a different disease and is beyond the scope of this review. Psychotic symptoms are more likely to occur in people with severe depressive illnesses and are thought to occur in approximately 20 percent of people with major depressive disorder.

For many people, depression starts with symptoms of sad mood or irritability and changes in sleep, energy or appetite. These symptoms progress to more serious symptoms of hopelessness, helplessness, guilt, worthlessness or suicidality. Should a person’s illness remain untreated, their depression can become psychotic. In certain cases, psychotic depression can be a psychiatric emergency due to the increased risk of suicide associated with this illness.

What causes psychotic depression?

At the current time, there is no definitive gene that is associated with psychotic depression. In spite of this, it is generally accepted that people with psychotic depression are more likely to have other family members with severe mental illness. Similarly, no specific region of the brain or chemical is thought to “cause” psychotic depression. Scientists have found that people with psychotic depression are more likely to have changes in their neurotransmitters and hormones than people with non-psychotic depression.

It is generally thought that women are more likely than men to experience psychotic depression. As with other mental illnesses, psychotic depression can occur in people of all races, ethnicities, and socioeconomic backgrounds.

What are the treatments of psychotic depression?

People with psychotic depression are at increased risk of suicide and therefore often require inpatient psychiatric hospitalization until their symptoms can be treated effectively. At the current time, there are no FDA-approved treatments for psychotic depression. In spite of this, there is good evidence that two treatment options are successful for psychotic depression: the combination of antidepressant medications and antipsychotic medications or the use of electroconvulsive therapy (ECT). As with any other mental illness, individuals and their families should discuss all treatment options with their psychiatrist.

ECT is the most effective treatment available for people with severe psychiatric illness and—in some cases—can achieve life-saving results in less than a few weeks. ECT does have significant side effects in many people—including impaired memory—but remains the treatment of choice for people in need of rapidly effective treatment due to poor nutrition, suicidal thoughts, and other severe complications of psychotic depression.

Antidepressants have been used in combination for almost half a century in the treatment of psychotic depression. These medications are usually helpful but may take up to a few months before their full effect is seen.

The role of psychotherapy cannot be understated in the treatment of psychotic depression. While psychotherapy is not indicated as the primary treatment of this illness, evidenced-based treatments such as cognitive behavioral therapy (CBT) can be very helpful as secondary treatments in psychotic depression.

What is the prognosis of psychotic depression?

With effective treatment, most people with psychotic depression will experience significant recovery. In spite of this, the severity of this illness and the fact that relapses are not uncommon suggests that ongoing treatment—including antidepressant medications and psychotherapy—to prevent relapse is indicated for most people.

Family and friends can be most helpful in providing empathic and non-judgmental support of their loved one and by encouraging them to continue treatment with their psychiatrist. With this support and proper psychiatric care, most people with psychotic depression can go on to live meaningful lives with their loved ones.

Reviewed by Jacob L. Freedman, M.D., and Ken Duckworth, M.D., May 2013