Psychotic Depression

Major depressive disorder is a mental health condition that affects more than 16 million adults every year. A certain percentage of this group will develop symptoms of psychosis (primarily delusions and hallucinations) as their depression progresses, and they may require hospitalization if their psychosis rises to the level of a medical emergency. Fortunately, psychotic depression responds well to a long-term treatment regimen that includes medication and psychotherapy.

What Is Psychotic Depression?

The symptoms of major depression are intense, troubling, and disabling. But in some cases, depression can become so severe that it causes a literal break with reality.

People who suffer these effects may be diagnosed with major depressive disorder with psychotic features, which is also known as psychotic depression. Men and women with this condition experience a series of hallucinations and delusions that cause them to see, hear, or sense things that aren’t really there, or believe things that are both false and irrational.

The distorted perceptions associated with psychosis are common to other forms of mental illness, but when psychosis combines with depression it often creates a medical emergency that must be dealt with immediately. A period of hospitalization may be required when psychotic depression develops, since untreated psychosis can lead to self-destructive actions or reckless behavior that puts other people at risk.

Types of Psychotic Depression

When psychosis develops in the wake of major depression, it can manifest in one of two forms: mood-congruent or mood-incongruent.

Mood-congruent psychotic symptoms are thematically consistent with the emotions and ideas normally associated with depression. Hallucinations and delusions will reinforce feelings of failure, guilt, shame, and hopelessness, burying the depression sufferer even further in their self-defeating perspectives.

Mood-incongruent psychosis, on the other hand, produces symptoms that have nothing directly to do with depression but are common to psychosis in general. People experiencing mood-incongruent delusions and hallucinations may hear voices or experience thoughts that seem to come from outside themselves, and those voices and thoughts may instruct them to do harmful or self-destructive things. They may believe they’re blessed with great power to influence events; or conversely, they may feel persecuted by outside forces that are trying to destroy them.

While bipolar disorder is a separate condition from major depressive disorder, bipolar depression can also produce a psychotic break with reality. Bipolar psychosis can also produce mood-congruent or mood-incongruent symptoms, and bipolar depression may be inaccurately diagnosed as major depressive disorder with psychotic features if a person seeking treatment has yet to experience a manic episode.

Facts and Statistics

Each year, more than 16 million American adults (6.7 percent of the population) will suffer from major depression.

Epidemiological studies have revealed that somewhere between 15 and 19 percent of this group will experience hallucinations and/or delusions in conjunction with their depression, and as many as five percent (approximately three million people) will develop the symptoms of full-fledged psychotic depression.

Other studies confirm that up to 25 percent of those who are hospitalized for depression are actually suffering from major depressive disorder with psychotic features, which highlights how disruptive and dangerous this condition can be.

Symptoms and Diagnosis of Psychotic Depression

Psychosis may eventually develop in those suffering from depression. But before that happens, they will likely notice other telltale signs of a major depressive disorder, such as:

  • Loss of energy and motivation. Even the simplest tasks become difficult to complete for a depressed person, as their feelings of low energy and motivation become constant companions.
  • Sleep disruptions. One sure sign of depression is a deterioration of sleeping habits: a person battling depression may have trouble going to sleep and may sleep much later than normal, or they may take frequent long naps at odd hours of the day.
  • Poor mental performance. People with depression usually have trouble concentrating, experience memory problems, struggle to make decisions, and in general seem disengaged from events going on around them.
  • Aches, pains, digestive problems, and other physical signs of distress. Depression is associated with a decline in physical health, which often manifests in a long menu of mysterious ailments that cannot be explained by medical doctors (people with depression often visit multiple doctors looking for answers).
  • Loss of interest in favorite hobbies or previously pleasurable activities. Depression robs a person of their capacity to feel joy, delight, surprise, or a sense of achievement.
  • Feelings of hopelessness, helplessness, emptiness, and despair. When a person suffers from depression their outlook on life decays and their optimism diminishes to a flicker. Life under the influence of depression takes on a surreal air, leaving sufferers feeling lost and without hope for a better future.

As depression deepens, vulnerability to psychotic episodes increases. Psychotic break symptoms cause changes in personality, behavior, and capacity to function, and may include:

  • Growing agitation and restlessness
  • Anxiety and panic attacks
  • Escalating complaints of pain or ill health
  • Further intellectual impairment
  • Bouts of physical immobility or unresponsiveness
  • Irritability and hostile responses
  • Paranoia, feelings of persecution
  • Odd and illogical speech or actions

Delusions and hallucinations will develop in the final phase of psychotic depression, and these symptoms of psychosis often cause significant interference in daily functioning that calls for rapid and intensive medical intervention. At this stage people can begin to lose touch with reality, making self-care virtually impossible.

Diagnosing Psychotic Depression

To receive a diagnosis for major depressive disorder with psychotic features, a person must demonstrate at least five of these known symptoms of depression for a period of at least two weeks:

  • Feelings of sadness or emptiness experienced on a daily basis
  • Significant loss of interest in, or ability to take pleasure from, a wide range of activities
  • Changes in appetite and/or weight
  • Changes in sleep patterns, such as insomnia or excessive sleep
  • Frequent agitation, or slowed motor functioning
  • Chronic fatigue and low energy
  • Pervasive feelings of worthlessness or guilt
  • Loss of ability to focus, concentrate, or make firm decisions
  • Frequent thoughts of suicide and/or death

The primary symptoms of psychosis are sensory hallucinations and delusions, which may manifest in a wide variety of forms. The exact nature of a person’s hallucinations and delusions are less important than their presence, however, which can severely interrupt daily functioning.

Regardless of the condition it accompanies, psychosis is diagnosed based on the results of interviews with patients and their family members. Depending on the severity of the symptoms and their speed of development, it may be diagnosed immediately or over the course of a few weeks, once its effects become clearer.

Despite its association with depressed states, bipolar psychosis is a different condition than psychotic depression. Nevertheless, until symptoms of mania are experienced and reported, bipolar psychosis may be misdiagnosed as major depressive disorder with psychotic features.

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Causes and Risk Factors for Psychotic Depression

The known risk factors for major depressive disorder with psychotic features include:

  • Exposure to childhood abuse and other types of early-age trauma
  • Genetic inheritance and/or family history of any mental illness (but especially mood disorders)
  • Previous incidence of psychiatric hospitalization
  • Brain injuries or diseases
  • Personal history of drug or alcohol use
  • Long-term loneliness and social isolation
  • Brain abnormalities, specifically in areas of the brain associated with stress responses and emotional regulation

The risk factors for bipolar psychosis are similar, and people who’ve experienced psychosis symptoms with any other illness (including bipolar disorder) may be vulnerable to psychotic depression later on in life.

Co-Occurring Disorders

Up to 70 percent of people with depression also suffer from anxiety disorders, while approximately half of all men and women with anxiety disorders have co-occurring depression. The cause-and-effect relationship between anxiety and depression is tangled and complex, but the two are so closely intertwined that mental health professionals know to look for one when the other is present.

Many people with depression choose to self-medicate with drugs and alcohol, and substance abuse is a risk factor for psychosis. About one-fifth of all mood disorder sufferers also have substance abuse issues, and likewise about 20 percent of people with substance use disorders have a history of mood and/or anxiety disorders—and each group shares an elevated risk for psychosis.

In addition to depression, psychosis can occur as a side effect of several other mental health disorders, including:

  • Bipolar disorder
  • Schizophrenia
  • Schizoaffective disorder
  • Schizophreniform disorder
  • Delusional disorder

Normally, mental health professionals must rule out these conditions before diagnosing psychotic depression. But in some instances, people with depression may have co-occurring disorders that can also produce psychotic break symptoms.

Psychotic Depression Treatment and Prognosis

People with psychosis may require emergency hospitalization before entering an inpatient or outpatient treatment program. During their hospitalization they may be administered antipsychotic medications such as Zyprexa, Seroquel, or Risperdal, which can stabilize their conditions by halting the progression of their hallucinations and delusions.

In formal inpatient or outpatient treatment programs for psychotic depression, psychotherapy in individual, group, and family formats will be combined with appropriate medications, which generally includes a mixture of antipsychotics and antidepressants. Treatment and rehabilitation may be further advanced through the addition of holistic healing practices, life skills classes, educational offerings, and any individualized services recommended by members of a patient’s treatment team. If a dual diagnosis for substance abuse has been made, treatment programs may include services specifically tailored to assist in the detox and recovery process.

Because of the disabling nature of the disorder, long-term treatment for psychotic depression is usually necessary. That may include an extended stay in residential inpatient treatment programs (90 days or longer), plus participation in aftercare regimens that continue for several months following the cessation of formal treatment.

Despite the frightening nature of this disorder, the long-term prognosis for psychotic depression is highly promising for patients who remain committed to their recovery programs. Psychotic depression is responsive to comprehensive treatment, and in the long run its most severe symptoms can be effectively managed or eliminated.