What is Psychotic Depression?

Psychotic depression, or major depressive disorder with psychotic features, is not something that first comes to mind when you find that someone is hearing voices or having paranoid delusions. Schizophrenia or bipolar disorder are usually at the tip of the tongue, but as one of the most underdiagnosed or misdiagnosed disorder, psychotic depression should become a part of the common canon of mental illnesses in our communities.

The big question has been – what is the difference between psychotic disorders, like schizophrenia, depression without psychotic features, and this psychotic depression. According to a published review of the current literature in 19921,

The review showed that statistically significant differences between the two types of depression have been found on each of these dimensions. There are greater guilt feelings and psychomotor disturbance, among other features, in psychotic depression. Studies have found significant differences between patients with psychotic and nonpsychotic depression in glucocorticoid activity, dopamine beta-hydroxylase activity, levels of dopamine and serotonin metabolites, sleep measures, and ventricle-to- brain ratios. Family studies show higher rates of bipolar disorder in first-degree relatives of probands with psychotic major depression than of probands with nonpsychotic major depression. Greater morbidity and residual impairment have also been reported in patients with psychotic major depression, and they respond more poorly to placebo and to tricyclic antidepressants.

Additionally, in 2006, there was a study2 that reviewed this by studying three groups of patients – each with one of the above disorders.

The severity of depressive symptoms in the depressed patients with and without psychosis was similar. The patients with psychotic depression were comparable to those with schizophrenia on the neuropsychological measures; they were more impaired than the patients with nonpsychotic depression on the measures of psychomotor speed, motor skills, attention, and learning.

Patients with psychotic depression seem to feel the worst of both worlds – severity of depression and deficits associated with psychosis. Additionally, in the diagnosis of psychotic depression, all psychotic symptoms (hallucinations, agitation, delusions, etc) are connected to the feelings for worthlessness, hopelessness, and despair and can come with a good dose of paranoia as well.

An unfortunate finding in comparing the types of depression is that the mortality rate is more than twice the rate for psychotic versus non-psychotic patients (41% compared to 20% in mortality within 15 years of initial hospitalization) and the suicide rate is five times higher3. These statistics also lead to this condition being considered a psychiatric emergency and treatment should be started immediately.

While treatments can be very effective, if properly diagnosed, with a combination of antipsychotic and antidepressant medications, relapses are common and prevention with this medication cocktail is essential. There is also some evidence that relapses do increase in severity. Electroconvulsive therapy (ECT) is also a recommended treatment for acute psychotic depression and is seen as a shorter-term solution for what will be a several month stabilization with medication and psychotherapy alone. However, psychotherapy is much less effective in treating this disorder.

The prevalence of psychotic depression is 4 per 1,000 people or 0.4% of the general population. However, in inpatient settings, 25% of patients meet the criteria for psychotic depression4. One of the most unique features of this diagnosis is that ability to have insight with psychosis, meaning that they have an awareness that the paranoia, delusions and hallucinations (visual or auditory) are, indeed, not real. For this very reason, many patients do not report these symptoms to their physician out of shame or fear.


1 Psychotic (delusional) major depression: should it be included as a distinct syndrome in DSM-IV?

American Journal of Psychiatry 1992 149:6, 733-745

2 Clinical and neuropsychological comparison of psychotic depression with nonpsychotic depression and schizophrenia

American Journal of Psychiatry 1996 153:4, 490-496

3 Psychotic depression and mortality.
Am J Psychiatry. 2003 Mar;160(3):574-6.

Vythilingam M1Chen JBremner JDMazure CMMaciejewski PKNelson JC.
4 Rothschild, A. J. (2013). Challenges in the Treatment of Major Depressive Disorder With Psychotic Features. Schizophrenia Bulletin39(4), 787–796. http://doi.org/10.1093/schbul/sbt046



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