Psychotic Depression

Estimated reading time: 25 minute(s)

Depression is one of the most common mental health conditions across the world. While most people experience the characteristic symptoms, like changes in appetite, low mood, and loss of interest, others may exhibit some unusual psychotic manifestations. Characterized by hallucinations and delusions, psychotic depression is a subtype of clinical depression that poses an additional threat to a person’s safety.[1] The condition is a combination of depression and psychosis and can be harder to manage. Understanding what is psychotic depression and its symptoms can help people get a timely diagnosis and seek help.

What Causes Psychotic Depression?

So far, experts have been unable to identify a single cause that potentially triggers psychotic depression. Some proposed causes may include the following:


People whose first-degree relatives or loved ones suffer from depression are more likely to experience psychotic depression.

Environmental Factors

Exposure to stressful or traumatic experiences, especially in childhood, may also raise a person’s risk of experiencing depression.

Biology and Brain Chemistry

Imbalances in natural brain chemicals, such as serotonin and dopamine, can also trigger many mental health conditions, including psychosis and depression. Some evidence also suggests the role of cortisol in triggering this type of depression. [2]

Who is at Risk of Developing Psychotic Depression?

Surveys suggest that up to 11 percent of individuals are likely to experience severe depression throughout their life. Of these populations, 14 to 18.5 percent will eventually develop psychotic features. The risk of developing psychotic depression increases as a person ages.

Since the definition of psychotic depression and the measurement tools for this condition are constantly evolving, the statistics continue to change. So far, experts believe that the following risk factors can make a person prone to developing psychotic depression.

  • Belonging to the female gender
  • Not having any loved ones or close friends to confide in
  • A family history of mental health illness
  • Having infrequent contact with loved ones
  • Experiencing a major adverse event in the past year
  • Living with chronic pain or other long-term illness
  • Undergoing major hormonal changes, such as menopause or postpartum changes
  • Ongoing monetary difficulties
  • A family history of schizophrenia, bipolar disorder, etc.
  • Belonging to an older age group, as aging increases the risk
  • Surviving extreme trauma or stress

Remember that it is impossible to predict who will develop psychotic depression as experts do not know much about the causes.

Psychotic Depression Symptoms

For people with psychotic depression, the manifestation is a mix of depressive and psychotic symptoms. The following are the signs of major depression:

  • Struggling to concentrate or make decisions
  • Experiencing a persistently sad, empty, hopeless, or low mood or feeling as if their life is worthless
  • Experiencing unexplained, sudden changes in body weight and appetite
  • Losing interest in activities you previously used to enjoy
  • Having way less energy than usual or struggling with lingering fatigue
  • Sleep-related difficulties, such as sleeping much less or more than usual
  • Frequent thoughts of dying, suicide, or death
  • Frequent feelings of helplessness, worthlessness, guilt, and self-hatred

Psychosis, on the other hand, can cause a person to disconnect from reality, meaning that a person experiencing it may not appreciate the symptoms. The common psychotic symptoms may include the following:

  • Having delusions or beliefs that aren’t true
  • Hallucinations, i.e., hearing, feeling, and seeing things that are not there
  • A state of stupor which makes it difficult for a person to speak, move, or respond normally
  • Psychomotor impairment
  • Slowed movements, feelings, or thoughts

Note that hallucinations and delusions can be of different types. In the case of psychotic depression, these may involve the following:

  • Constantly believing that you suffer from a serious health disorder despite the possibility of being ruled out on multiple tests
  • Hearing voices that are constantly mocking or criticizing you
  • Believing you have special powers that others don’t
  • Seeing a threatening or dangerous animal following you
  • Experiencing an irrational fear or suspicion of other individuals
  • Believing yourself to be a historical figure or a famous person

Psychotic Depression Test and Diagnosis

People experiencing depression with psychotic features may not always seek help on their own. In many cases, their loved ones have to step up to help them find an appropriate mental health facility to formulate a formal diagnosis and commence treatment. For formulation of a diagnosis, a professional usually begins by asking questions about a patient’s mood, mental health, and emotional well-being. The questions are generally directed towards the following:

  • Persistent worries that might be affecting daily life
  • Fixed beliefs that may not be necessarily true
  • Anything you hear, see or feel that no one else can notice
  • Your current relationships and support network
  • Problems with eating, sleeping, or going about the daily life
  • Any health concerns
  • Personal and family history of physical and mental health
  • Presence of any other mental health symptoms, such as mania and anxiety

In many cases, the psychotic picture may not be clear in people with depression. Even trained clinicians may be unable to pick it up immediately or struggle to differentiate between fixed delusions and rumination, a pattern of dark, gloomy, and unwanted thoughts. Hence, experts constantly encourage patients to describe their exact feelings, beliefs, and perceptions to the clinicians to support them in making the right diagnosis.

Remember that to formulate the diagnosis of major depression with or without psychosis, the symptoms must:

  • Last for at least two weeks or more
  • Affect certain areas of everyday life
  • Not be associated with any other psychiatric illness or substance use

Psychotic Depression Treatment

According to the latest psychotic depression treatment guidelines released by the American Psychiatric Association, most people would benefit from a combination of medications and electroconvulsive therapy. Note that this combination stands as the first-line treatment for psychotic depression.


Most experts prescribe antidepressants or antipsychotics to manage the symptoms of psychotic depression. In terms of antidepressants, the popular choices include serotonin-norepinephrine reuptake inhibitors (SNRIs) and serotonin reuptake inhibitors (SSRIs). Evidence also suggests that combining these antidepressant drugs with an antipsychotic drug is more useful than using either of them alone.

However, it is imperative to remember that both categories of medications come with certain side effects. For example, research has found that adding an atypical antipsychotic medicine, such as aripiprazole, risperidone, or quetiapine, to an antidepressant medication can increase the risk of mortality. However, researchers also admit that more in-depth investigations are needed to understand this risk. It is also imperative to consider that every situation is different from the other, and some people may benefit more from the combination than getting harmed. A doctor is the best person to determine if combining antidepressant medications with antipsychotic drugs can be beneficial for someone.

Electroconvulsive Therapy

Also known as ECT, electroconvulsive therapy is a safe and effective way to seek treatment for psychotic depression. The therapy remains reserved for people who fail to respond to traditional medications. Since ECT delivers rapid relief, it also remains the therapy of choice for people exhibiting suicidal thoughts. Despite being a rapid treatment modality, ECT is also a type of ongoing treatment that requires the use of antidepressants to prevent recurrences in the future.


What is the difference between major depression and psychotic depression?

Major depression, also known as clinical depression, can affect your behavior, mood, physical health, and daily life. An episode of this type of depression typically includes a loss of interest in daily activities along with a persistently low mood for two weeks, along with 4 out of the 9 significant symptoms of depression. Psychotic depression is when a person starts experiencing additional symptoms apart from the usual depressive manifestations, including hallucinations and delusions. Remember that it is uncommon for a person with major depression to have delusions or to hallucinate.

How long does psychotic depression last?

The duration of psychotic depression may last for a variable amount of time. For some, it may resolve within one month while for others, the condition may continue for over six months or even longer.


1 Gaudiano BA, Dalrymple KL, Zimmerman M. Prevalence and clinical characteristics of psychotic versus nonpsychotic major depression in a general psychiatric outpatient clinic. Depress Anxiety. 2009;26(1):54-64. doi: 10.1002/da.20470. PMID: 18781658; PMCID: PMC3111977.

2 Cherian K, Schatzberg AF, Keller J. HPA axis in psychotic major depression and schizophrenia spectrum disorders: Cortisol, clinical symptomatology, and cognition. Schizophr Res. 2019 Nov;213:72-79. doi: 10.1016/j.schres.2019.07.003. Epub 2019 Jul 12. PMID: 31307859.

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