Depressive Psychosis: Definition, Symptoms, And Treatment Options

Medically reviewed by Julie Dodson, MA
Updated May 15, 2024by BetterHelp Editorial Team
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Major depressive disorder with psychotic features (depressive psychosis) is a serious manifestation of major depressive disorder characterized by a combination of severe depression and delusional thinking, possibly heightened by hallucinations. Also known as psychotic depression, depressive psychosis may occur due to external stress and trauma combined with a major depressive episode. However, the cause of psychotic depression is not entirely understood. 

People living with bipolar disorder may also experience psychosis during a depressive episode. Understanding psychosis alongside depression may help you understand if you're facing this challenge and how to find support. 

Wondering if depressive psychosis can be helped by therapy?

Depressive psychosis defined

Psychosis involves an episode of losing touch with reality and experiencing delusional thinking. In some cases, it can involve hallucinations of visual, auditory, or tactile stimuli that are not present. For example, someone experiencing depressive psychosis may hear the voices of people who aren't present or believe someone is trying to poison them. Psychosis can also involve confusing or incoherent thoughts and speech alongside a feeling of dissociation (being disconnected from your body).

Major depressive disorder with psychotic features is a severe mental health condition, especially when left untreated. Suicide, self-harm, or accidents may be of concern with psychotic depression since the person believes what they are experiencing is real or that they don't have control over it. 

The National Alliance on Mental Illness (NAMI) estimates that approximately 20% of people with major depression also have symptoms of psychosis.

Furthermore, three out of 100 people experience at least one psychotic episode that results in hospitalization. For every four people who end up in the hospital because of depression, one may develop and present symptoms of depressive psychosis.

Symptoms of depressive psychosis

Depressive psychosis presents similarly to depression, with additional indicators. Symptoms of psychotic depression can include the following: 

  • A lack of interest or decline in caring for one's physical and mental health 
  • A loss of interest in previously enjoyed activities 
  • Difficulty thinking clearly
  • A new or returning suspicion about people and situations 
  • Feeling that one's paranoia is "normal" 
  • Rejecting another person's attempt to reason 
  • Social withdrawal 

Keeping an eye out for the above symptoms or noting them may help you or those you love to realize when a depression-related psychotic episode is occurring. As the symptoms of depressive psychosis become more severe, you may experience irritability or anger, isolate yourself, or communicate less with others, so early detection may be beneficial. 

How is MDD with psychotic features diagnosed? 

A psychotic depression diagnosis is often made when depressive symptoms last for two weeks or longer and at least five of the following symptoms are present:

  • Difficulty falling asleep or sleeping too often 
  • A lack of energy 
  • Slow movements or motor function
  • Appetite changes 
  • Irritability or unfounded feelings of guilt 
  • Hopelessness or sadness 
  • False or delusional beliefs 
  • Difficulty getting through the day or completing daily tasks
  • Preoccupation with thoughts of suicide, death, and self-harm

In addition to the above symptoms of mental illness, the individual may display symptoms of psychosis like delusions and hallucinations. Delusions are mood congruent or incongruent, and hallucinations can take the form of voices or images in someone's head, sometimes related to touch and smell.

Mood-congruent delusions can include and involve feelings of guilt, inadequacy, and feelings of being persecuted. In this case, the delusions make sense with the person's current state of mind and mood, including depressive symptoms. For example, believing that you are worthless or don't deserve happiness because you failed an exam indicates a mood-congruent delusion.

Mood-incongruent delusions conflict with a person's state of mind and mood. These delusions do not have a depressive theme or involve feelings of guilt, death, or feeling inadequate. For example, believing you are a superhero or can fly is a delusion. These are uplifting thoughts that may not make sense with depression. Fearful delusions like a fear of being followed or hurt can also be mood-incongruent, even though they have negative themes. 

Psychotic depression is a chronic condition lasting upwards of two years. Between episodes, the individual may function normally and meet their social and professional obligations with little difficulty. In addition, they may have other depressive episodes without psychosis present. 

What causes psychosis during a depressive episode?

There is no specific medical or scientific method of predicting or knowing why someone may develop depressive psychosis. However, research indicates that some factors may be present that put certain individuals at a higher risk. These factors can include the following: 

  • A traumatic event 
  • Genetics and family history
  • Addiction or a substance use disorder 
  • Physical illness

Mental health specialists diagnose depressive psychosis when their clients meet the criteria outlined in DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) for major depressive disorder, mood-incongruent, and mood-congruent psychotic features. To be diagnosed with MDD with psychotic features, you must first meet the diagnostic criteria for major depressive disorder. 

Wondering if depressive psychosis can be helped by therapy?

Treatment options

According to the National Institute on Mental Health, the earlier a person begins treatment for psychotic depression, the more effective it may be. Treatment for depressive psychosis is often a combination of therapy and medications, including antidepressants and antipsychotics. However, consult your doctor before starting, changing, or stopping a medication. 

Finding the right combination and dose of medication that best works for your body and condition may take time. You and your healthcare provider may try a few combinations before finding a suitable dosage. It may take a month of regular use before the medication begins to fully work and relieve psychiatric symptoms. Be sure to talk with your healthcare provider to clarify questions about side effects and efficacy. 

Electroconvulsive therapy

Another method of treating major depressive disorder with psychotic features is electroconvulsive therapy. According to the American Psychiatric Association, electroconvulsive therapy is a medical treatment effective in treating bipolar disorder or severe major depressive disorder. Psychotic depression treated with ECT is an option for severe cases of depressive psychosis where suicide is a risk or when the symptoms are not responsive to medications and therapy. 

ECT involves using brief electrical stimulation of the brain while the client is under anesthesia. These electrical currents are applied to balance the neurotransmitter levels in the brain. Side effects of electroconvulsive therapy may include temporary memory loss and difficulty learning. Other side effects of ECT that occur the same day of treatment include nausea, fatigue, headache, and confusion. ECT is often administered alongside other treatments like medications and psychotherapy. 

Alternative support options 

A diagnosis of depressive psychosis can be life-changing and significantly impact you and your loved ones. However, with appropriate treatment, the success rate of recovering from depressive psychosis and regaining the quality of your life can be high. Improvement might be noticed as quickly as a few months after the start of treatment. 

For some people, living with anxiety or depression can make it challenging to make appointments and commute to therapy. Online therapy through a platform like BetterHelp may reduce this barrier, as you can talk to a therapist from home. In addition, you can save money by not paying for gas or a parking spot. Rates of online therapy can also be hundreds of dollars cheaper for many clients, depending on location and therapist rates. 

Research supports the efficacy of online therapy, indicating it can be as effective as in-person therapy with the added benefit of convenience and flexibility. However, note that depressive psychosis can be serious. Talk to a psychiatrist or another medical doctor about your treatment options if you're not responding to therapy. 


Major depressive disorder with psychotic features is a mental illness listed under the depressive disorders category in the DSM-5. It involves symptoms of depression and psychosis simultaneously. If you think you might be living with this condition or are concerned that someone you love is, consider reaching out to a licensed therapist for guidance and support. You're not alone, and treatment is available.
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