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Psychotic Depression

by National Institute of Mental Health
December 6, 2007
There’s depression, which if you have depression, most people have. And then there’s psychotic depression, or more technically known as major depressive disorder with psychotic features. This is a far less common disorder than simple depression.
Psychotic depression is characterized by not only depressive symptoms, but also by hallucinations (seeing or hearing things that aren’t really there) or delusions (irrational thoughts and fears). Often psychotically depressed people become paranoid or come to believe that their thoughts are not their own (thought insertion) or that others can ‘hear’ their thoughts (thought broadcasting).
While people with other mental illness, like schizophrenia also experience these symptoms, those with psychotic depression are usually aware that these thoughts aren’t true. They may be ashamed or embarrassed and try to hide them, sometimes making this variation difficult to diagnose. Risk of bipolar depression, recurring episodes of psychotic depression and suicide are increased after its onset.
Researchers aren’t exactly sure what causes major depressive disorder with psychotic features (psychotic depression), but it’s frequently associated with high levels in the blood of a hormone called cortisol ( Cortisol is an important steroid hormone produced by the adrenal glands. The blood levels of this hormone typically follow a pattern throughout the day, with the lowest levels occurring around 4 in the afternoon. More cortisol is released during times of stress — biological and psychological).
There are no obvious risk factors, though it is known that those with a family history of depression or psychotic illness will be more susceptible.
Symptoms of Psychotic Depression

Symptoms that occur more commonly in psychotically depressed patients include:

• Anxiety
• Agitation
• Hypochondria
• Insomnia
• Physical immobility
• Constipation
• Cognitive impairment

Treatment of Psychotic Depression

Treatment for psychotic depression requires a longer hospital stay and close follow-up by a mental health professional. Combinations of tricyclic antidepressants and antipsychotic medications have been most effective in easing symptoms. The addition of lithium to this combination can be beneficial for those with bipolar disorder. Electroconvulsive therapy is very effective for this condition, but it is generally a second line treatment.
Researchers are also studying the effectiveness of RU-486 (the “abortion pill” and “emergency contraceptive”), which is said to dramatically relieve psychotic depression.
Prognosis of Psychotic Depression

Treatment is very effective for psychotic depression and people are able to recover, usually within a year, but continual medical follow-up may be necessary. Generally, the depressive symptoms have a much higher rate of recurrence than the psychotic symptoms. It is important, however, that a person experiencing these symptoms be properly diagnosed because treatment is different than for other major depressive illnesses and risk of suicide is greater.