Psychotic Depression: Symptoms And Treatment

Medically reviewed by Melissa Guarnaccia, LCSW
Updated May 14, 2024by BetterHelp Editorial Team
Please be advised, the below article might mention trauma-related topics that include suicide, substance use, or abuse which could be triggering to the reader.
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Psychotic depression can be defined as an extreme form of major depressive disorder with psychotic symptoms, such as disorganized thoughts, paranoia, delusions, and hallucinations. Risk factors for developing psychotic depression can include childhood trauma, stressful life events, substance misuse, and comorbid mental health disorders. Support can be crucial when coping with psychotic depression. Turning to friends and family is often helpful, and working with a licensed mental health professional is also recommended. Cognitive-behavioral therapy, interpersonal therapy, and family-focused therapy are often beneficial. Sometimes, medication may be prescribed by a doctor or psychiatrist. If you’re living with depression, online therapy may help you manage symptoms and potentially prevent psychotic episodes.

Are you experiencing symptoms of psychotic depression?

Understanding psychotic depression

At its core, psychotic major depression (PMD) can be viewed as an extreme form of MDD with added psychosis. A person experiencing psychotic depression may be unable to distinguish between reality and their thoughts or beliefs. Hallucinations, paranoia, and delusions can be common features of psychotic depression, as can feelings of guilt and worthlessness.

In addition to these symptoms, people with psychotic depression may also experience changes in their behavior. People with psychotic depression may experience mood swings from severe depression to manic states. During the depressive phase, they may experience suicidal tendencies*, feel hopeless, and experience anxiety. However, during a manic phase, they may experience restlessness, impulsivity, and increased energy levels. These drastic mood swings often make it more challenging to diagnose and treat the disorder accurately.

In some cases, individuals with psychotic depression may experience some unique symptoms compared to those of major depressive disorder. These symptoms can include agitation, lack of appetite, significant weight loss, and prolonged periods of insomnia. The psychotic symptoms can also be physical, such as visual and auditory hallucinations or paranoia, and cognitive, such as disorganization in thought processes or difficulty concentrating.

Psychotic depression can affect people of all ages, races, and backgrounds. However, the misconceptions and stigma around psychotic depression can make it difficult for people to seek the help they deserve. For example, some may think that psychotic depression is something they can "snap out of" or simply "will away." However, this usually isn't the case; the condition typically requires professional help and treatment to manage symptoms.

Risk factors for psychotic depression

While the exact cause of psychotic depression may still be unknown, several risk factors can increase a person's likelihood of developing this condition. As we explore some of the major risk factors associated with psychotic depression, keep in mind that not everyone who experiences these factors may develop the disorder.

One of the primary risk factors for developing psychotic depression can be having a genetic predisposition to the condition. A predisposition generally means that individuals with a family history of psychotic depression may be more likely to develop the condition themselves. While genetics alone cannot fully determine whether someone will develop psychotic depression, it can play a role in increasing their risk.

Another major risk factor for psychotic depression may be exposure to environmental factors that may trigger the condition. Some of these factors may include the following:

Childhood trauma

Traumatic childhood experiences, such as abuse*, neglect, or a lack of emotional support, can increase a person's risk of developing psychotic depression later in life. These experiences can disrupt the development of the brain and ultimately lead to mental health concerns.

If you or a loved one is experiencing abuse, contact the Domestic Violence Hotline at 1-800-799-SAFE (7233). Support is available 24/7.

Stressful life events

Stressful life events, such as the death of a loved one, a divorce, or a job loss, can also trigger psychotic depression. These events can cause significant emotional distress and may leave a person overwhelmed and unable to cope.

Substance misuse

Substance misuse may be another environmental risk factor for psychotic depression. Substance misuse can lead to chemical imbalances in the brain and trigger a range of mental health conditions, including psychotic depression.

Comorbid mental health disorders

Individuals with comorbid mental health disorders, such as anxiety or bipolar disorder, may also be at an increased risk of developing psychotic depression. These conditions can interact, potentially making each one more severe and harder to manage.

While there may be no surefire way to prevent the development of psychotic depression, knowing the risk factors associated with the condition can help individuals take steps to safeguard their mental health. Whether through therapy, medication, or lifestyle changes, there may be ways to manage psychotic depression and reduce its symptoms.

Early signs of psychotic depression

Many people with psychotic depression may show early signs of the condition. If you know what to look for, it can help you identify the signs and seek out the necessary treatment. 

The early signs of psychotic depression can be divided into five categories, including emotional, cognitive, behavioral, physical, and social symptoms. Some of the most common symptoms can include those listed below.

  • Emotional Symptoms: Persistent sadness or low mood, feelings of worthlessness or guilt, suicidal thoughts or behaviors
  • Cognitive Symptoms: Difficulties with concentration and memory, delusions or false beliefs, and hallucinations
  • Behavioral Symptoms: Social withdrawal and isolation, neglect of personal hygiene, and erratic or disorganized behavior
  • Physical Symptoms: Insomnia or hypersomnia, appetite and weight changes, fatigue, or low energy
  • Social Symptoms: Withdrawal from friends and family, loss of interest in activities that were once enjoyed, difficulty communicating with others

If you notice any of these symptoms in yourself or a loved one, it may be time to seek professional help. A mental health provider can assess the situation and provide you with the necessary treatment and support.

The importance of support systems

As you manage your symptoms, it can be important to remember that you are not alone. There may be various support systems available to help you cope with this condition, such as family and friends, support groups, online communities, and mental health professionals.

Having a strong social support system can be essential for managing psychotic depression. Family and friends can provide emotional support and comfort, while support groups can help you connect with others who have similar experiences. Online communities can also be a helpful resource for finding understanding and guidance, as well as tools to help you manage the condition.

Mental health professionals can be another important resource for managing psychotic depression, as they can provide psychotherapy and other forms of treatment.

Cognitive behavioral therapy

Cognitive-behavioral therapy (CBT) is a type of psychotherapy that usually focuses on identifying and changing negative thoughts and behaviors. CBT can help people change how they think and act by teaching them coping skills, managing stress, and finding healthier ways to manage symptoms.

Interpersonal therapy

Interpersonal therapy (IPT) is another form of psychotherapy that can help individuals manage their relationships to improve mental health. IPT can help people develop better communication skills, understand their emotions and reactions to others, and improve relationships with family, friends, and coworkers.

Family-focused therapy

Family-focused therapy can also be helpful, as it typically promotes family support and understanding in coping with the condition. During these sessions, the family will likely work together to identify and address any issues contributing to the individual's depression. Family can provide much-needed support and guidance by creating a more positive and understanding environment.

No matter what type of treatment you choose, having a strong support system can make it easier to manage your symptoms and live a happier, more fulfilling life. With the right resources and support, you can take control of your mental health and well-being.

Benefits of online therapy

Online therapy has become increasingly popular for those living with mental health conditions. With online therapy, you can get hold of qualified therapists from the comfort of your own home. Online therapy can provide a safe space for individuals to discuss their thoughts and feelings without judgment or stigma, which may help those living with depression feel more comfortable and at ease. Please note that those who are experiencing severe symptoms of psychosis, such as hallucinations, delusions, and the potential to harm oneself or others, may require in-person treatment.

Effectiveness of online therapy

A 2022 study indicates cognitive-behavioral therapy, a modality often employed in online therapy, may effectively manage psychotic depression. By preventing the first episode of psychosis in ultra-high-risk individuals and improving depression, self-esteem, and psychological well-being, CBT can be an important tool in recovery. Individuals can take charge of their mental health through CBT techniques like cognitive restructuring, problem-solving, and relaxation.

In addition, a 2020 systematic review suggested that online CBT could be more effective than in-person CBT for treating depressive disorders, showing that online therapy may be a valid choice for many people experiencing depression.

Are you experiencing symptoms of psychotic depression?


The severity of psychotic depression can greatly impact an individual's life due to symptoms like paranoia, hallucinations, delusions, and disorganized thoughts. Those who have experienced stressful life events, childhood trauma, comorbid mental health disorders, and substance misuse may be at higher risk for developing psychotic depression, although it is not guaranteed that people with these risk factors will experience this disorder. Interpersonal therapy, cognitive-behavioral therapy, and family-focused therapy, as well as medication, can be recommended if you’re living with psychotic depression. One way to connect with a therapist who practices these types of therapy may be through an online therapy platform.
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