What Is Major Depression With Psychotic Features?

Depressive psychosis, also known as major depression with psychotic features, is a form of depression involving psychosis and depression symptoms simultaneously. This mental health condition is separate from schizophrenia and is considered a subtype of a depressive disorder. Psychosis can consist of disordered thoughts, disorganized behavior, delusions, and hallucinations. Psychotic depression is often treated with a combination of therapy and medication.

What is psychosis? 

Psychosis is often described as a loss of touch with reality, and psychotic symptoms can include the following:

• Delusions (false beliefs)

• Hallucinations (auditory, visual, tactile, etc.) 

• Disordered thoughts

• Disorganized behavior

• Psychomotor agitation

People experiencing psychotic episodes may struggle to distinguish between real and unreal and experience paranoid thoughts. Speech may be unclear and disorganized. 

Psychosis can lead to a significant decrease in overall functioning, and people with this symptom may demonstrate weaker performance in ordinary activities or neglect them entirely. These activities may include social events, hobbies, school or work responsibilities, and personal hygiene. In extreme cases, an individual may need to go to the hospital for a short period of time to manage psychosis.

How psychosis can relate to depression

For some individuals, severe depression symptoms or a depressed mood might be accompanied by psychosis. Common symptoms of depression include the following: 

• Prolonged sadness, guilt, and hopelessness

• Difficulty with sleep (insomnia or hypersomnia) 

• Fatigue and lethargy

• Lack of motivation

• Substance abuse and use of drugs

• Appetite changes

• Sleep changes

• Psychomotor retardation

• Pushing away friends and family members

Due to the bleak feelings that can come with depression, someone experiencing psychosis may have negative but delusional beliefs. For example, they may believe an adverse event will occur or that others are watching them. Psychosis during depression may be more harmful or scary for the individual, whereas psychosis in a condition like bipolar disorder during mania (increased energetic states) may look more like delusions of grandeur. 

Psychotic depression is believed to affect around four per 1,000 people in the general population, but for people who have major depression, the statistics can be considerably higher. In the United States, 14.7% of adults living with clinical depression have also displayed psychotic features. In Europe, 18.5% of adults have psychotic features in addition to major depressive disorder. 

Because psychosis is often a symptom of an underlying mental illness, psychotic depression is not categorized as a standalone mental condition in the most current versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). However, it can be significant enough to be considered a subtype of depression and may warrant similar, yet more specialized, treatment.

Psychotic depression is a serious illness, studies have shown that individuals with psychotic depression are at an increased risk of suicidal ideation and are twice as likely to die by suicide when compared with individuals with non-psychotic depression. If you or a loved one is experiencing suicidal thoughts, reach out for help immediately. The 988 Suicide and Crisis Lifeline can be reached at 988 and is available 24/7.

Additionally, some features of psychosis and depression can overlap and intensify others. For instance, it can be common for people who experience depression to withdraw and lose interest in activities they once enjoyed. Still, when facing psychosis simultaneously, these aspects may be prolonged or prominent.

Major depression with psychotic features vs. schizophrenia

Although psychosis is often associated with psychotic disorders in the DSM-5, like schizophrenia, it can also be experienced in other cases. Schizophrenia is a separate mental illness often characterized by psychotic features, but it has different symptoms than major depressive disorder in many cases. 

For people with psychotic depression, psychotic features may be episodic and occur mainly alongside episodes of severe major depression, whereas with schizophrenia, psychosis can be present without any mood disorder.

However, individuals living with schizophrenia can be diagnosed with a depressive disorder and have psychosis simultaneously. Many of the symptoms of schizophrenia can be similar to those of major depression. However, schizophrenia and depression may have different biological markers, such as activity in the hypothalamic-pituitary-adrenal axis.

Despite often being a severe form of major depression, major depressive disorder with psychotic features may be misdiagnosed or undiagnosed. Although psychosis can sometimes be apparent, it can also be subtle, depending on the context. If the person is not displaying any unusual behavior during the examination, like delusional thinking, this can contribute to a misdiagnosis.

In addition, a person with psychotic depression may recognize that their thoughts and impressions are unusual and choose to keep them to themselves. Conversely, they may not realize their psychosis is out of the ordinary. For example, some thoughts, such as delusions of guilt and persecution, may not seem delusional at first glance. This can cause more harm as an individual goes without treatment for psychotic depression. 

Psychologists diagnosing psychotic depression correctly can help clients receive the most effective treatment and experience positive health outcomes.

How is major depression with psychotic features treated

There are few peer-reviewed studies on treatment options for major depressive disorder with psychotic traits. However, some experts suggest treating psychotic depression with a combination of therapy and medication, as with MDD. If you’re considering medication or antidepressants, consult your primary care physician or psychiatrist before starting or changing any medical treatment. 

In terms of medication, people with psychotic depression may benefit from antipshcotic medications. However, further medically reviewed research is needed to highlight the efficacy of these medications, especially in the treatment of psychotic depression.

Electroconvulsive therapy

When symptoms of psychotic depression are not responding to treatment, it is known as treatment-resistant depression. In this case, electroconvulsive therapy (ECT) can be particuarly effective. During electroconvulsive therapy, licensed practicioners can reduce depressive psychosis by generating localized electrical currents in the brain. This form of therapy (ECT) is used in the treatment of various mental disorders, and has proven to be especially effective in the treatment of psychotic depression, bipolar disorder, and severe depression.

While this form of treatment is more invasive than traditional therapeutic approaches, it is considered to be highly safe. Before engaging in electroconvulsive therapy it’s important to seek medical advice from a mental health professional. Regardless of its safety and efficacy, there can still be side effects such as fatigue, headache, and confusion. 

Counseling options 

Depression can make it challenging to fulfill the responsibilities of everyday life and enjoy the activities you used to enjoy. Therapy is another method of treatment for psychotic depression. Working with a therapist can allow you to discuss your depression safely and receive validating advice and other treatment for psychotic episodes. Therapists can create personalized treatment plans according to various factors, such as your family history, experience with other health conditions, and psychotic symptoms. Health conditions such as multiple sclerosis can be a risk factor for developing both psychotic and nonpsychotic depression. Therefore, a detailed medical history will help a therapist during the assessment and diagnosis phase. For patients experiencing symptoms of depression, it can be challenging to leave home, especially after a depressive episode. In these cases, online therapy can be effective.  

According to one study, the severity of participants’ depression symptoms significantly decreased after treatment with an online therapist. Through an online platform, you can choose between phone, video, and live chat sessions and receive personalized care from any location with an internet connection. 

If you’re ready to get started, online therapy platforms like BetterHelp can match you with a provider able to meet your needs based on your responses to your initial questionnaire upon signing up. Many therapists online are educated in depressive disorders, and there are hundreds of therapy modalities that clients can try.