Most people are familiar with the term depression, but many may not have heard of a more nuanced condition called psychotic depression. Psychotic depression, or Major Depression with psychotic symptoms, is a more severe form of depression, where an individual experiences both psychotic and depressive symptoms. Individuals with psychotic depression experience a combination of symptoms leading to significant impairment in their daily life.
Educating individuals experiencing major depression with psychotic symptoms and their families can help reduce stigma. This can lead to the development of more peer support groups and community resources.
Understanding this condition, and its differentiation from other disorders will help with accurate diagnosis, improved individual outcomes, and the opportunity for ongoing research.
Understanding psychotic depression
Major depression with psychotic symptoms is a distinct mental health condition that differs from major depressive disorder (MDD). MDD is categorized by persistent feelings of sadness and a lack of interest in things that previously brought joy.
Psychosis is a mental disorder that is characterized by a disconnection from reality. Two types of psychosis include hallucinations and delusions.
Individuals with psychotic depression experience the symptoms of both major depression and psychosis. Psychotic depression requires a different treatment approach where both the depressive and psychotic symptoms are addressed.
Prevalence and demographic data
Since psychotic features are frequently missed in depressed patients, the true prevalence of psychotic depression is likely to be underestimated. In a study sample of 16,423 respondents, the lifetime prevalence rates of psychotic symptoms were 11.6%. Latinos and Black people had higher lifetime rates (13.6% and 15.3%) than White people (9.7%) and Asians (9.6%). This indicates that there may be differences in the prevalence of psychotic symptoms among different ethnic groups.
Research suggests that there is a strong association between major depressive episodes and the presence of hallucinations and delusions. A study found the likelihood of having both hallucinations and delusions was nine times higher in individuals with a major depressive episode than in those without.
Symptoms of psychotic depression
Depression manifests through a range of emotional and cognitive symptoms that can significantly affect an individual’s daily life. Emotionally, individuals can experience sadness, worthlessness, hopelessness, and emptiness.
Common symptoms of depression
Anhedonia, a term used to describe the inability to experience joy or pleasure, is a common symptom of depression. Individuals who experience this have a loss of interest in the activities or things that they once enjoyed.
Fatigue is also a common symptom of depression. It makes it difficult for the individual to complete simple tasks. Insomnia, or hypersomnia (excessive sleeping) are sleep-related symptoms that can cause fatigue. Without adequate sleep, individuals can experience cognitive impairment and a reduced ability to cope with stressors.
Psychotic symptoms
Psychosis is the term for symptoms that happen when a person has trouble telling the difference between what’s real and what’s not. This disconnection from reality can happen for several reasons, including many different mental and physical conditions.
Delusions are false beliefs that are held even when there is ample evidence against them. Some people hold these false beliefs very strongly, even when others don’t believe them or there’s plenty of evidence that it isn’t true. For example, people with delusions of grandeur may believe they possess special abilities that they don’t actually have or that they are a powerful figure, such as a religious or political leader.
Hallucinations occur when parts of your brain mistakenly interpret sensory signals and replicate them leading to inaccurate sensory perceptions such as seeing, hearing, touching, smelling, and tasting. An example of a hallucination is hearing voices that aren’t there (auditory hallucination).
Impact on daily functioning
The combination of depression and psychosis can have an impact on an individual’s ability to express themselves clearly and rationally. This may cause individuals to isolate themselves which can lead to further exacerbated symptoms.
When experiencing psychosis, performing job tasks effectively and efficiently could be difficult. Decreased productivity and frequent absences are possible outcomes when psychosis is untreated.
When experiencing a delusion or hallucination during an interaction, an individual living with psychotic depression can become confused or distressed. This may lead to social withdrawal and isolation. These individuals may also experience difficulty maintaining self-care such as personal hygiene and a balanced diet.
Causes of psychotic depression
The cause of psychotic depression varies. Biological factors like genetic family history, psychological factors such as trauma, and environmental factors can all play a part in the development of psychotic depression. Let’s take a closer look at how exactly these factors can influence the development of this mental health condition.
Biological factors
Did you know that a family history of psychotic depression is more likely for individuals diagnosed with it? Genetic studies show that psychotic depression has a strong familial link and a significant heritability (39%). Researchers have found specific locations on chromosomes that possibly indicate an increased risk of developing psychotic depression.
Neurotransmitter imbalances, which occur when there is a disruption of serotonin, dopamine, and norepinephrine, can lead to other symptoms of depression.
Psychological factors
A history of childhood trauma is significantly higher in psychotic patients. Furthermore, growing up in an abusive, toxic, or unsafe household can disrupt normal childhood development and affect how the brain responds to stress.
Experiencing severe stress such as dealing with a chronic illness can contribute to the development of depression and psychosis. Life events such as divorce or the loss of a child can negatively impact an individual’s mental health.
Environmental factors
Individuals from a lower socioeconomic status may experience limited job opportunities and low income. Persistent financial stress or experiencing multiple hardships, such as homelessness or poor living conditions, may increase the risk of developing depression or the likelihood of psychosis.
Having access to quality medical care can be a challenge for some individuals. Barriers such as lack of insurance, limited access to services, or high out-of-pocket costs can lead to delayed treatment and worsening symptoms.
Without a support system, individuals are more likely to experience isolation and loneliness which can exacerbate depressive symptoms and potentially trigger psychotic symptoms. Support systems can provide emotional support for individuals experiencing psychotic depression.
Diagnosis
For a diagnosis of psychotic depression, clinical assessments are utilized by medical providers to effectively diagnose and treat individuals who are suspected of having the condition. In addition to the assessments, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines a list of criteria associated with the diagnosis.
Diagnostic criteria
According to the DSM-5 , to diagnose Major depressive disorder an individual must have five or more of the following symptoms, have been present during the same 2-week period, and represent a change from previous functioning.
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day
- Diminished ability to think or concentrate, or indecisiveness, nearly every day
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for dying by suicide
The Psychotic Depression Assessment Scale (PDAS) is an 11-item scale that covers both depressive and psychotic symptoms. The Revised Behavior and Symptom Identification Scale (BASIS-R) is a 24-item self-report instrument with six scales, including depression/functioning, interpersonal relationships, self-harm, emotional lability, psychosis, and substance abuse. Despite there being a vast majority of rating scales that can be used to assess psychotic depression, more research is needed to validate rating scales for accurate diagnosis and treatment.
Importance of early detection
Psychotic depression requires immediate medical care and treatment. Developing an awareness of this mental illness can help with beginning a conversation with others about it and reduce fear around asking for help. Detecting the signs and symptoms involved in depression can help prevent the condition from worsening, reducing its impact on the individual’s life and well-being.
Differential diagnosis
Psychotic depression may have similar symptoms to other disorders such as schizophrenia and bipolar disorder. In schizophrenia, the psychotic symptoms are more persistent and they do not have to occur with mood symptoms. Individuals diagnosed with bipolar disorder experience mania or hypomania which is not present in psychotic depression. Psychotic depressive symptoms occur exclusively during depressive episodes.
Treatment options
When it comes to treating psychotic depression, there are a number of options to choose from. By consulting with a licensed mental health professional, you can discuss you goals and they will help develop a treatment plan that’s right for you. Let’s take a look at your options.
Pharmacological treatments
Typically, medication treatment involves a combination of antidepressants and antipsychotics. Psychotic depression medications help balance neurotransmitters in the brain. It is recommended that individuals with psychotic depression engage in a combination of pharmacological treatment along with talk therapy and follow advice from a licensed provider.
Psychotherapy
If you identify with feelings of overwhelm or hopelessness, having the support of a mental health professional can tremendously help you understand those feelings and where they come from.
Treatment for psychotic depression can include cognitive behavioral therapy. This model of therapy helps individuals identify and challenge irrational thoughts or beliefs that are contributing to their psychosis or depression symptoms. It includes implementing coping strategies to help manage symptoms and it encourages changing thoughts and behaviors.
Psychodynamic therapy helps with uncovering the unconscious processes that are contributing to behavior and emotions. The therapist will discuss past experiences and how they may contribute to psychotic depression.
Family therapy allows family members to be a part of their loved one’s treatment. Therapists can provide psychoeducation to family members during family sessions to help everyone understand what is going on.
Electroconvulsive therapy
Electroconvulsive Therapy (ECT) may be recommended for severe depression that hasn’t responded to medication or therapy. ECT is considered effective and safe for individuals with thoughts of suicide, psychosis, and catatonia. This involves a series of treatments that stimulate the brain with a controlled voltage of electrical current. The current creates a mild seizure, which affects the levels of neurotransmitters.
Possible risk factors with ECT are short-term memory loss, nausea, headache, and fatigue. Although ECT can be effective, symptoms can return, therefore ongoing treatment may include talk therapy and medication.
Hospitalization
A medical provider may recommend a stay at a psychiatric hospital to treat psychosis if it is severe or if an individual is displaying erratic behavior or experiencing persistent thoughts of harming themselves or others. The risk for suicide is much higher in people with depression with psychotic symptoms than in those without psychosis.
Hospitalization for an individual who is experiencing psychotic depression may be necessary to ensure safety and stabilize their mental state. The criteria for hospitalization generally include a risk of harm such as suicidal or homicidal ideations or behaviors, increased severity of symptoms, lack of support system, and the professional judgment of a medical provider.
Ways therapy can help
Therapy plays a crucial role in managing psychotic depression by addressing both the depressive and psychotic symptoms through various therapeutic approaches. It offers a safe space for individuals to explore their emotions, develop effective coping mechanisms, and build stronger relationships with others. By working closely with mental health professionals, individuals can receive personalized care tailored to their unique needs.
Personalized treatment plans
Therapists work collaboratively with clients to create a tailored approach that considers their specific symptoms, challenges, and goals. This individualized care plan may include a combination of psychotherapy, medication management, and other therapeutic interventions.
Development of coping strategies
Therapy for psychotic depression can include coping strategies such as mindfulness and relaxation exercises when symptoms occur. Techniques that help with grounding or stress reduction can also be effective coping strategies.
Support in medication management
Therapists can provide support to their clients by helping them process emotions about what it’s like to take medications and come up with skills for maintaining compliance around the medications. Furthermore, the therapist can monitor progress and report to the client’s prescriber for a collaborative strength-based approach.
Improving interpersonal relationships
Therapists can help clients diagnosed with psychotic depression with communication skills to help enhance their relationships. Therapists can also teach clients how to resolve conflicts and build social skills.
Education and support for families
A therapist can provide support to the family of the person diagnosed with psychotic depression by providing psychoeducation on the condition and information on family support groups.
The road to improved mental health
Psychotic depression is a mental health condition that can seriously impact the life of the person with it, as well as their loved ones. Recognizing the symptoms early and seeking medical treatment promptly can help with the individual’s quality of life. Effective treatment includes a multifaceted approach that provides talk therapy, medications, and access to inpatient facilities. To create a supportive environment for individuals coping with psychotic depression, continued research, and stigma reduction are needed. This will help to improve treatment outcomes and provide better care for individuals with this condition.
Experiencing the symptoms of psychotic depression can seem overwhelming, confusing and isolating. Seeking professional help is an important step to take toward wellness.
If you or someone you know is thinking about suicide, call or text 988 at or chat 988lifeline.org. You can also call 1-800-273-8255 (1-800-273-TALK). The 988 Suicide and Crisis Lifeline provides free and confidential support 24/7, anytime day or night.
You can also call 911 or the local emergency number or go to the hospital emergency room. DO NOT delay.
If someone you know has attempted suicide, call 911 or the local emergency number right away. DO NOT leave the person alone, even after you have called for help.
If you or someone you know is struggling with psychotic depression, seeking help is vital. Grow therapy has a wide array of therapists, counselors, and psychiatric providers with different backgrounds who are equipped to treat individuals with psychotic depression as well as many other mental health disorders. Take action and schedule an appointment with a Grow provider so that you may start your journey towards a more satisfactory mental well-being.
