Psychotic Depression: Symptoms And Treatment

Updated February 03, 2021

Medically Reviewed By: Lauren Guilbeault

Psychotic depression is much more common than one might think. This is a very serious form of depression that affects about 20 percent of the people diagnosed with clinical depression or major depressive disorder. In fact, the condition may be even more common. It is difficult to assess just how common psychotic depression is because it often goes undiagnosed.

It is important that if you are experiencing extreme depression with psychotic features that you understand the illness and how it is treated. Most people who seek treatment for psychotic depression experience complete remission of symptoms within one year. It is a very treatable illness, but you must first understand what it is, how it affects you, and how it is treated.

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Psychotic Depression Definition

Psychotic depression is a severe form of depression in which the depressed individual has a break with reality. They may have delusions, hallucinations, or thought disruptions. Some people with psychotic depression are also paranoid and have anger management issues. In many ways, the psychotic features that are present in this form of depression are similar to schizophrenia, although there are some distinct differences.

Difference Between Psychotic Depression And Schizophrenia

Individuals diagnosed with schizophrenia can simultaneously become depressed. So how do you tell the difference between schizophrenia with depression and psychotic depression? The difference is important in the way they are treated and diagnosed.

The biggest difference between schizophrenia and psychotic depression is that in psychotic depression the patient often recognizes that the hallucinations, delusions, and thought disruptions are not real. They understand that something is very wrong with them and that these thoughts are not based in reality. Schizophrenia patients believe that their thoughts, hallucinations, and delusions are the reality.

Psychotic Depression Symptoms

Psychotic depression comes with a variety of symptoms. In addition to symptoms of major depression, there are also symptoms of some sort of psychosis. Not everyone with psychotic depression will experience the same symptoms. It is very rare that individual displays every single one of the possible symptoms of depression and psychosis.

Depressive Symptoms

Psychotic depression comes with the same potential symptoms that all serious depressive disorders come with. Major depressive disorder and persistent depressive disorder are the two primary types of clinical depression. For either of these, at least five of the following symptoms must be present. For major depressive disorder, symptoms last for at least two weeks. For persistent depressive disorder, symptoms last for two years or more.

The common symptoms of depression are:

• Crying, feelings of sadness or hopelessness
• Irritability and easily frustrated
• Loss of interest in most activities
• Changes in sleep pattern, such as insomnia or sleeping too much
• Fatigue and lack of energy
• Changes in appetite, such as lack of appetite or eating too much
• Increased anxiety and feelings of restlessness
• Slowed thinking and movements
• Self-blame, feelings of worthlessness
• Difficulty concentrating or thinking

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Psychotic Symptoms

With psychotic depression, you will have some of the symptoms of depression as well as symptoms of psychosis. When at least one or two of these psychotic symptoms are present during an episode of depression, it constitutes psychotic depression.

• Constipation
• Physical immobility
• Increased agitation
• Cognitive impairment, such as poor memory and unorganized thinking
• Hypochondria
• Hallucinations
• Delusions
• Paranoia

Diagnosis Of Depression With Psychotic Features

A diagnosis of depression with psychotic features is a difficult one for doctors to make. Most people with psychotic depression cannot stop the hallucinations, delusions, paranoia, or unorganized thinking, but they know that these things are not real. They realize that something is wrong, and they are embarrassed about these thoughts and things happening to them.

Because of this cognitive ability to know that their break with reality is just that, many people who have psychosis with their depression never mention those symptoms to their doctor. They are either embarrassed or afraid of the diagnosis. So they simply do not mention these symptoms. While it is estimated that about 20 percent of people with depression experience some type of psychosis, this is just an estimate because it is assumed that many people are not diagnosed correctly.

It is extremely important that if you have depression and are seeking treatment and experience any of the symptoms of psychosis that you mention these symptoms to your doctor. Treatments for depression alone will not resolve your symptoms. You will require different methods of treatment for psychotic depression, and those treatments cannot be administered or effective if you are not completely open and honest with your psychiatrist and therapist.

Measuring Psychotic Depression

Measuring psychotic depression is a difficult task. There are many measurements of the severity of depressive disorders. Several different depression scales have been developed for use in different groups and situations. However, no scale exists to measure psychotic depression.

Many psychiatrists and therapists use two scales to measure the severity of the illness, the Hamilton Depression Rating Scale (HDRS) and the Brief Psychiatric Rating Scale (BPRS). However, this can be time-consuming and frustrating for the patient as they are asked question after question.

The National Institute for Mental Health has come up with a solution. They took the six items from the HDRS melancholia subscale and five items from the BPRS scale to create a specific scale for measuring the severity of psychotic depression. They call this scale the HDRS-BPRS scale. Studies of this scale have found it to be very effective and accurate. It is also much easier to administer the assessment because there are fewer questions and they are easier for the patient to answer.

Treatment Of Major Depression With Psychotic Features

Treatment of major depression with psychotic features presents a challenge to psychiatrists and therapists. Typical treatments for depression, including cognitive behavioral therapy and antidepressants, are not sufficient to reduce symptoms in psychotic depression.

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Because psychotic depression includes a psychosis and breaks with reality, initial treatment is often inpatient to carefully monitor the patient and administer intense treatment. Once symptoms have lessened, and it is clear that the patient is not a danger to themselves or others, they may be released from the behavioral hospital and continue treatment on an outpatient basis.

There have been many research studies done to try to determine the most effective treatments for psychotic depression. These treatments almost always include a combination of antidepressants and antipsychotic medications. Not much research has been done into what psychotherapy may be effective. Additionally, when medications do not seem to be lessening symptoms, ECT treatment may also be administered and is found to be effective.

To better understand the challenges faced by doctors in the treatment of psychotic depression, and to better determine the best treatments, the National Institute of Mental Health did an extensive analysis of the potential treatments and their effectiveness. This study is the most comprehensive of its kind, and effective treatments are summarized in the next several paragraphs.

Medication Treatment

Medication treatment for psychotic depression usually consists of an antidepressant combined with an antipsychotic medication. However, the studies on these have been sporadic and usually, consist of trials for specific combinations. It is important to note that not every combination will work for every patient. It may take some trial and error to find the right combination of medications that will reduce symptoms.

Some of the medication combinations that have been studied and found to be effective include:

• Venlafaxine and quetiapine
• Sertraline and olanzapine
• Fluoxetine and olanzapine
• Amitriptyline, haloperidol, and trimipramine
• Nortriptyline and perphenazine
• Amoxapine, amitriptyline, and perphenazine
• Amitriptyline and perphenazine

Other combination of antidepressants and antipsychotics may also be valid. More studies need to be done as to the effectiveness of additional combinations of medications. However, these are the most studied combinations and the most frequently prescribed.

Psychotherapy Treatments

There have not been many studies as to the effectiveness of psychotherapy for psychotic depression. By far the rule of thumb seems to be that those with psychotic features are excluded from depression trials. It is generally assumed that cognitive behavioral therapy, the most common psychotherapy for depression without psychotic features, is not effective when psychosis is present.

However, there are some newer methods of psychotherapy that have begun to show promise in the treatment of psychotic depression. These are Behavioral Activation Therapy and Acceptance and Commitment Therapy (ACT). Behavioral Activation therapy focuses on replacing behaviors consciously. Acceptance and Commitment therapy focuses on accepting the illness and committing to treatment.

ECT Treatment

When medical therapy is proving to be ineffective, ECT therapy may be administered. In severe cases where a fast reduction in symptoms is required, ECT may be the first line of treatment. While ECT used to be performed only on an inpatient basis, it is becoming more common for it to be performed on an outpatient basis several times a week for several weeks.

ECT therapy stands for electroconvulsive therapy. During ECT therapy, electrodes are placed on the patient's scalp, and electrical currents are applied. This is done while the patient is sedated, and there is no pain for the patient. It is one of the safest and most effective treatments for psychotic depression.

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There are some side effects of ECT treatment. Many patients experience short-term memory loss after treatment and may continue to have problems with memory as treatments progress. Typically, memory loss resolves itself over time, although the period of months when ECT was administered may always be "fuzzy" in their remembrance.

Getting Help

If you have symptoms of psychotic depression, it is extremely important that you seek out help right away. Psychotic depression is very treatable, but it will not get better unless you seek treatment. It is also very important that you are completely honest with your therapist or psychiatrist about your psychotic symptoms so that a proper diagnosis can be made, and treatment tried. Contact a therapist today to start yourself on your path to better health.