Psychotic Depression: Symptoms, Causes, Treatment

Introduction – Psychotic Depression: Symptoms, Causes, Diagnosis, Treatment, and Coping

Psychotic Depression, (major depression with psychotic features), is listed in the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5) as a subtype of major depressive disorder (MDD). This mental health condition is a combination of symptoms of major depression and symptoms of psychosis (a break from reality), though not to be confused with standalone psychosis and schizophrenia. While it’s estimated that 0.4% of adults have psychotic depression—though this percentage is likely higher—the condition is often misdiagnosed or inadequately treated. 

If you or someone you know has psychotic depression, or if you could be experiencing symptoms of psychotic depression, please consult with a mental health professional right away. Treatment is available to help you manage your symptoms and prevent future relapse. 

Here, we discuss the symptoms of psychotic depression, along with potential causes, diagnosis, treatment, and ways to cope. 

Symptoms of Psychotic Depression

The onset of psychotic symptoms alongside major depression can be scary and often debilitating. Due to the severity of symptoms, psychotic depression can also increase the risk of self-harm and thoughts of suicide. While the mental health community acknowledges the severity of this condition, there is still a lack of research available, causing professionals to sometimes miss the onset of symptoms or confuse them with the manifestation of other mental health conditions. 

Additionally, whether due to fear, shame, or other various reasons, individuals experiencing symptoms do not always report them openly, increasing the odds of being undiagnosed or misdiagnosed—both of which can be of grave, and potentially, life-threatening concern.

To fully understand the manifestation of psychotic depression, it’s helpful to first cover the symptoms of major depression. Per the American Psychiatric Association (APA), it’s estimated that one in 15 adults is affected by depression and one in six people will experience a form of depression during their lifetime.

Symptoms of Major Depressive Disorder include:

• Depressed mood
• Loss of interest or pleasure in most activities
• Intense feelings of sadness, guilt, and/or hopelessness 
• Fatigue and/or exhaustion
• Withdrawn behavior (avoiding family, friends, or usual activities)
• Psychomotor retardation or agitation
• Changes in appetite and weight
• Insomnia or hypersomnia
• Difficulty thinking and concentrating
• Frequent or recurrent thoughts of death, suicidal thoughts, and/or past suicide attempts

Symptoms of psychotic depression include a range of depressive symptoms in combination with symptoms of psychosis (a break or disconnect from reality), such as: 

• Hallucinations (seeing, hearing, and/or feeling the sensation of things that aren’t real)
• Delusions (believing things that aren’t true)
• Increased anxiety
• Agitation
• Psychomotor impairment
• A state of stupor (being unable to move, speak or respond to one’s given environment)
• Increased risk of self-harm, harm to others, and/or thoughts of suicide 

Causes of Psychotic Depression

While the causes of psychotic depression are not certain, there are risk factors to consider such as early life trauma and a predisposition for mental health issues. Anthony Rothschild, MD, a professor at the Irving S. and Betty Brudnick Endowed Chair of Psychiatry, University of Massachusetts Medical School, explains how losing a parent before age 11—or any trauma such as sexual or physical abuse—puts someone at risk for psychotic depression. If an individual with this risk factor experiences clinical depression as an adult, they become even more at risk. 

Risk factors for developing clinical depression can include brain chemistry, hormone fluctuations, medical conditions, genetics, environmental conditions (experiences of trauma and/or high-stress situations).

People of all ages can develop psychotic depression, but symptoms are often seen in older adults—in their 60s, 70s, and 80s—and can arise despite there being no prior mental health history. 

How to Diagnose

When diagnosing Major Depressive Disorder, an individual’s symptoms must persist for two weeks or longer and must include 5 or more symptoms listed in the DSM-5—with one of those symptoms being either 1) depressed mood or 2) loss of interest and pleasure. Symptoms must also cause an individual significant distress or impairment in daily functioning, must not be related to the effects of substances or a medical condition, and must not be better explained by another mental health condition. Additionally, individuals should not have a history of mania or hypomania. 

To make a diagnosis of Major Depressive Disorder with psychotic features, an individual must meet the criteria for a diagnosis of major depression while also having symptoms of psychosis, such as hallucinations and/or delusions. 

Such features must be interpreted as either mood-congruent (relating to common depressive themes such as low self-worth and hopelessness) or non-mood-congruent (apart from common depressive themes)—with mood-congruent psychotic features being more generally seen. Features of psychosis are also more likely to manifest as delusions, with or without hallucinations, than hallucinations alone; particularly, by way of nihilistic type delusions (a belief that either oneself, a part of one’s body, or the world does not exist or has been ruined). 

Treatment is Available

There is treatment available for psychotic depression: medication (typically in the form of an antidepressant and antipsychotic) and electroconvulsive therapy (ECT) are most commonly used in the initial treatment phase. Individuals and their families will need to discuss the best treatment modality for them with their mental health provider. 

Typically, inpatient treatment is required to closely identify and monitor symptoms of psychosis as well as to stabilize an individual on medication. Some individuals may start to feel better rather quickly once treatment is initiated but it’s critical to continue the treatment regimen and maintain follow-up appointments to prevent future relapse. Individuals will also benefit from continued psychotherapy with a provider they can be open and honest with.

Coping With Psychotic Depression 

As difficult as a diagnosis of psychotic depression can be, remember that it’s a temporary state and no one is alone in going through this. Symptoms of psychosis are likely to decrease sooner than symptoms of depression which may help reorient someone to a more familiar routine and headspace while addressing other symptoms. 

In treatment, addressing symptoms of psychosis will take precedence (for the safety of the individual and to ensure the safety of others) but many coping techniques can be utilized while on the track to increased health and wellness. 

Let’s take a look at a few. 

• Focus on self-care: Prioritizing your physical, emotional, and mental health can help ease feelings of uneasiness and increase self-esteem.
• Connect with others: Building and maintaining a support network can promote feelings of safety and security.
• Educate yourself:  For many, understanding their diagnosis and researching it can help to decrease negative feelings surrounding the condition.
• Maintain a routine: Structure can increase focus, decrease anxiety, and bring a sense of accomplishment.
• Limit screen time and social media use: Exercising the mind in productive, dynamic ways can help boost dopamine and serotonin.
• Stay up to date with appointments: Schedule your annual health appointments and stay up to date on any psychiatry or therapy appointments to monitor your progress. When you take care of your mind and body, you become in tune with your inner self and more aligned with your aspirations.  
• Don’t be afraid to ask for help. You don’t have to do this alone. Support is available. Remember – your mental health condition does not define you and seeking help is not a sign of weakness, but great strength.

Featured Image Credit: Photo by Andre Moura (Pexels)

References

1. American Psychiatric Association. (2020, October). What Is Depression? https://www.psychiatry.org/patients-families/depression/what-is-depression
2. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
3. Black, R. (2022, September 14). Psychotic depression: What it is and what you should know. https://www.psycom.net/depression/psychotic-depression 
4. Major depression with psychotic features. Mount Sinai Health System. (n.d.). https://www.mountsinai.org/health-library/diseases-conditions/major-depression-with-psychotic-features 
5. Rothschild AJ. Challenges in the treatment of major depressive disorder with psychotic features. Schizophr Bull. 2013 Jul;39(4):787-96. doi: 10.1093/schbul/sbt046. Epub 2013 Apr 18. PMID: 23599251; PMCID: PMC3686458. https://pubmed.ncbi.nlm.nih.gov/23599251/