Some people who have severe clinical depression will also experience hallucinations and delusional thinking, the symptoms of psychosis.
Depression with psychosis is known as psychotic depression.
Symptoms of severe depression
Someone with
severe clinical depression feels sad and hopeless for most of the day, practically every day, and has no interest in anything. Getting through the day feels almost impossible.
Other typical symptoms of severe depression are:
- fatigue (exhaustion)
- loss of pleasure in things
- disturbed sleep
- changes in appetite
- feeling
worthless and guilty
- being unable to concentrate or being indecisive
- thoughts of death or suicide
Read more about the psychological, physical and social symptoms
of clinical depression
Symptoms of psychosis
Having moments of psychosis (psychotic episodes) means experiencing:
- delusions – thoughts or beliefs that are unlikely to be true
- hallucinations – hearing and, in
some cases, feeling, smelling, seeing or tasting things that are not there; hearing voices is a common hallucination
The delusions and hallucinations almost always reflect the person's deeply depressed mood – for example, they may become convinced they're to blame for something, or that they've committed a crime.
"Psychomotor agitation" is also common. This means not being able to relax or sit still, and constantly fidgeting.
At the other extreme, a person with psychotic depression may have "psychomotor retardation", where both their thoughts and physical movements slow down.
People with psychotic depression have an increased risk of thinking about suicide.
What causes psychotic depression?
The cause of psychotic depression is not fully understood. It's known that there's no single cause
of depression and it has many different triggers.
For some, stressful life events such as bereavement, divorce, serious illness or financial worries can be the cause.
Genes probably play a part, as severe depression can run in families, although it's not known why some people also develop
psychosis.
Many people with psychotic depression will have experienced adversity in childhood, such as a traumatic event.
Read more about the causes of clinical depression
Treating psychotic depression
Treatment for psychotic depression involves:
- medicine – a combination of antipsychotics and antidepressants can help relieve the symptoms of psychosis
- psychological therapies – the 1-to-1 talking therapy
cognitive behavioural therapy (CBT) has proved effective in helping some people with psychosis
- social support – support with social needs, such as education, employment or accommodation
The person may need to stay in hospital for a short period of time
while they're receiving treatment.
Electroconvulsive therapy (ECT) may sometimes be recommended if the person has severe depression and other treatments, including antidepressants, have not worked.
Treatment is usually effective, but follow-up appointments so that the person can be closely monitored are usually required.
Getting help for others
People with psychosis are often unaware that they're thinking and acting strangely.
As a result of this lack of insight, it's often down to the person's friends, relatives or carers to seek help for them.
If you're concerned about someone and think they may have psychosis, you could contact their social worker or community mental
health nurse if they've previously been diagnosed with a mental health condition.
Contact the person's GP if this is the first time they've shown symptoms of psychosis.
If you think the person's symptoms are placing them or others at possible risk of harm you can:
- take them to your nearest accident and emergency (A&E) department, if they agree
- call a GP or local out-of-hours GP
- call 999 to ask for an ambulance
Further
information
The following websites provide further information and support:
- SANE
- Mind: psychotic experiences
Driving
If you've
been diagnosed with psychotic depression, it's your legal obligation to tell the Driver & Vehicle Licensing Agency (DVLA). It could affect your ability to drive.
Visit GOV.UK for more information about medical conditions, disabilities and driving
DEFINITION
- A common, chronic, treatable mood disorder that typically follows a remitting and relapsing course of depressive episodes.
- Depressive episodes are characterized by:
- Persistent low mood
- Decreased self-attitude—a distinctly lower sense of self-esteem and self-confidence compared to usual for the individual
- In the most severe cases, these manifest as guilt and hopelessness.
- Decreased mental and physical energy (vital sense), which reduces one’s daily functioning
EPIDEMIOLOGY
- Lifetime prevalence for women, 10-25%; men, 5-12%[1]
- The wide variation in prevalences
is of concern.
- Higher prevalence estimates with questionnaire- or criterion-based interviews (such as the SCID) administered either in person or by phone (especially in recent years)
- Lower prevalence estimates with clinician evaluations (usually following a symptomatic screening procedure)
- There is no widely accepted method to divide cases meeting screening criteria into groups of major depressive disorder (MDD) and non-MDD depression (recurrence, number of symptoms,
duration of episodes, and treatment-seeking are often cited to indicate robustness of the diagnosis of MDD).
- Rates are equal for pre-pubescent boys and girls; rates in women following menarche are twice that of men.
- Age of onset is typically in early twenties, but earlier and later onset occur.
- Common psychiatric comorbidities include substance abuse,
anxiety disorders, panic disorders, and personality disorders.
- Increased risk if female; Native American; middle-aged; widowed, separated, or
divorced; or low-income[1]
- Decreased risk if Asian, Hispanic, or black[1]
- High
comorbidity with anxiety disorder, substance use disorders, general medical conditions
- Major depression has a familial component; individuals with a first-degree relative with major depression have increased risk of developing bipolar disorder and major depression.
DIAGNOSIS
- Major depressive episodes are characterized by the triad of low mood, self-attitude, and vital sense.[2]
- Low mood may manifest
as persistent sadness, anxiety, apathy, irritability, or emotional numbness.
- Most often a combination of these plus anhedonia
- Low self-attitude may manifest as self-blame, self-deprecation, guilt, lack of self-confidence about the future, or hopelessness.
- Low vital sense may manifest as
decreased attentiveness to work tasks, decreased energy and/or concentration, indecisiveness, or physical slowing.
- Helpful but less consistent signs include changes in sleep patterns (especially early a.m. awakening) or appetite (overeating or undereating), reduced libido, and diurnal variation in symptoms (with early a.m. worsening), recurrent thoughts of death,
suicidality.
- To qualify as a major depressive episode the symptoms must cause distress or impairment in functioning and not be due to alcohol, another substance, or a general medical condition.
- Presence of psychotic features (e.g.
hallucinations or delusions) with major depressive episodes reflects severe disease and is a poor prognostic indicator.
- Mood-congruent
psychotic symptoms: delusions of guilt, worthlessness, bodily disease, or impending disaster; or condemnatory auditory hallucinations
- Mood-incongruent psychotic symptoms: persecutory or self-referential delusions, or hallucinations without affective content
- Most patients return to normal mood between episodes, although around 20% of people have residual mood symptoms or chronic
depression.
- Episodes can be triggered by stress, loss (e.g. death of loved one, separation by divorce, unemployment), sleep deprivation, drug and alcohol use.
- Depression is a clinical syndromal diagnosis based on history and mental status examination. To date, there is no valid diagnostic laboratory test.
- Tests to assess etiologic factors include CBC, BMP, LFTs, TSH, B12, folate, Vitamin D, RPR, blood alcohol level, urinalysis, and urine toxicology.
- The US Preventive
Services Task Force recommends screening adults for depression at general medical visits when staff-assisted depression care supports are in place for better diagnosis and treatment.
- Screening for suicide potential has been shown to be of little or no value.[3]
- Screening is
useful to increase detection but is neither highly sensitive nor specific.
- Two-question depression screening (low mood and anhedonia) is equivalent to most other MDD screening
scales.[4][5]
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- //www.phqscreeners.com/images/sites/g/files/g10060481/f/201412/PHQ-9...
- Adjustment disorder
- Persistent depressive disorder (dysthymia)
- Bipolar disorder
- Cyclothymic disorder
- Schizophrenia
- Schizoaffective disorder
- Anxiety disorder
- PTSD
- Delirium
- Central nervous system diseases can produce a true depressive syndrome:
- Parkinson disease
- Dementia
- Neoplasm
- Huntington disease
- Stroke
- Epilepsy
- B12 deficiency
- Substance use or withdrawal (alcohol, opiates, cocaine,
cannabinoids, hypnotics)
- Personality disorders are associated with a higher risk of MDD but are likely aggravating factors rather than causative.
- Medications (antihypertensives, steroids, chemotherapy)
- Sleep-related disorders (OSA)
- Endocrine disorders (hypothyroidism, Cushing disease, prolactinoma)
- Infectious diseases (Lyme disease, mononucleosis, HIV, CNS syphilis)
- Inflammatory conditions (SLE, multiple sclerosis)
- Anemia
- Wilson disease
TREATMENT
- A combination of medication and individual psychotherapy
is usually best.
- Psychoeducation and supportive therapy can be administered in the acute phase of severe MDD. The focus is support and education. Extremely severe depression makes any formal psychotherapy very difficult, until some improvement in concentration and hopefulness develops.
- Family involvement and supervision can be very helpful at times (to prevent a suicide attempt, non-suicidal self injury, substance use, and disordered eating behavior). Family participation can be
very helpful to provide critical history, as well as to help patients remember and interpret what clinicians have told them or instructed them to do.
- Phases of depressive illness:
- Acute: inform the patient of the diagnosis; educate, support, and assure safety
- Hospitalization is needed if there are life-threatening medical problems, psychosis, or moderate-to-high risk of suicide.
- In more severe cases, medications are usually required.
- For the most severe
cases, ECT has a high probability of success.
- Education for the family should emphasize that the patient’s mood symptoms are due to a treatable illness, that the patient must continue taking his/her medication and come to appointments, and that suicide is not acceptable.
- Improvement: serial mental status assessments, support, identification of stressors and relationship issues (important in all stages of illness)
- Maintain effective medical treatment.
- Carefully
reduce purely symptomatic medications (e.g., benzodiazepines).
- Recovery: long-term medication management (at least 6-12 months)
- More intensive psychotherapies are more effective.
- Preventive strategies to reduce the likelihood and severity of future episodes.
- Remission rates are low (~30%), but ~60% of moderate and severe cases of MDD will improve significantly with antidepressant treatment.
- Antidepressants include SSRIs,
TCAs, SNRIs,
MAOIs, buproprion, and mirtazapine.
- Antidepressant choice depends on history of response, family history of response, tolerability, adverse effects, and likelihood of adherence.
- Clinical trials show little difference in efficacy or tolerability among
SSRIs and other classes of antidepressants.
- SSRIs are first-line choice
due to minimal side effect profile.
- In order to "fail" an anti-depressant trial, a patient must remain on a therapeutic dose of anti-depressant for 6-8 weeks.
- Failure of one SSRI, does not mean failure of all SSRIs, so patient should trial another SSRI.
- If a patient fails two SSRIs, the next choice can be an
SNRI, TCA, or adjunct anti-depressant (e.g. buproprion or SNRI) or augmenting agent.
- Combination therapy with a reuptake inhibitor and an antagonist of presynaptic α2-autoreceptors may be superior to monotherapy, and may be beneficial as first-line therapy for severe depression or treatment nonresponders.[6]
- Fluoxetine may be safer in children and adolescents,
and is the only SSRI consistently show to be effective in this population.
- Mood symptoms should be carefully monitored as anti-depressants can trigger manic episodes.
- Mood stabilizers can augment the effects of antidepressants and help prevent a switch to mania.
- Antipsychotics are combined with
antidepressants to treat psychotic depression and treatment-resistant depression. One should be cautious about long-term use and dose should be decreased as permitted.
- Benzodiazepines can be used during the acute phase for anxiety and insomnia. Avoid in elderly due to risk of delirium.
- To
improve medication compliance with an outpatient, have a follow-up visit one week after starting, ask about side effects, and re-educate about the time required for a valid therapeutic trial (8 weeks).
- Over 70% of patients who stop taking anti-depressant in 5 weeks or fewer after they become symptom-free will relapse, so careful monitoring of medication compliance is important.
- Supportive therapy is important and well-received in severe, acute phases of illness.
- CBT, interpersonal therapy, and problem-solving therapy are all helpful and delay relapse for mild and moderate
depression.
- Psychotherapy alone is not first-line treatment for severe depression, or in psychotic or bipolar forms.
- Remission rates with ECT are 60-80% in severe MDD.
- ECT can be first-line treatment for severe MDD with psychosis, psychomotor retardation, or catatonic features; medication resistance; or pregnancy.
- Supplemental treatments include regular sleep, bright light therapy, physical activity, healthy eating habits, no alcohol or drugs, distracting
activities, and a regular schedule.
- PCPs manage the majority of patients with MDD.
- A UK study showed that PCPs identified depression in almost half of cases.
- 35% to 50% of MDD cases go unrecognized; in addition, MDD is often untreated when
diagnosed.[7]
- MDD overdiagnosis and overtreatment are also common in community
settings.[8]
- Referral to a psychiatrist is indicated if patient requires adjunct anti-depressant treatment, has co-morbid psychiatric diagnoses including substance abuse,
anxiety, panic attacks, or psychotic features such as hallucinations or
delusions, or has thoughts of death or harming others.
- A person who is actively suicidal should be referred to the closest emergency department for
hospitalization.
FOLLOW UP
- Individual psychotherapy needs will change as the patient improves.
- There is an increased risk of suicide in first 30 days, and also in first year following hospitalization for MDD.
COMMENTS
- MDD is associated with other specific psychiatric disorders, notably substance dependence,
panic and generalized anxiety disorders, and several personality disorders. If present, these will need to be addressed during
treatment.
- 90% of completed suicides have a diagnosed psychiatric disorder; 70-80% meet criteria for MDD; and comorbid alcohol use disorder is common (15-30%).
- If the patient has long-term overuse of addictive substances, specific treatment is usually required.
- Elderly patients
often manifest depression as somatic symptoms (e.g. fatigue, abdominal pain, headache, confusion, memory loss).
- Increased prevalence estimates of MDD (28% increase) and anxiety disorders (26% increase) during the early phase of the
COVID-19 pandemic may be inflated. Robust trauma research has shown that resilience or recovery typically follow negative life events (e.g., bereavement or disaster
exposure).[9]
References
- Hasin DS, Goodwin RD, Stinson FS, et al. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions.
Arch Gen Psychiatry. 2005;62(10):1097-106. [PMID:16203955]
DePaulo, Jr., J.R, & and Ablow, K. (1989). In McGraw-Hill (Ed.), How to cope with depression. A complete guide for you and your family. Ballantine Books.
- Gilbody S, Sheldon T, House A. Screening and case-finding
instruments for depression: a meta-analysis. CMAJ. 2008;178(8):997-1003. [PMID:18390942]
- Whooley MA, Avins AL, Miranda J, et al. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997;12(7):439-45. [PMID:9229283]
- Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284-92. [PMID:14583691]
- Henssler J, Alexander D, Schwarzer G, et al. Combining Antidepressants vs Antidepressant Monotherapy for Treatment of Patients With Acute Depression: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2022. [PMID:35171215]
- Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet. 2009;374(9690):609-19. [PMID:19640579]
- Mojtabai R. Clinician-identified depression in community settings: concordance with structured-interview diagnoses. Psychother Psychosom. 2013;82(3):161-9. [PMID:23548817]
- Daly M, Robinson E. Depression and anxiety during COVID-19. Lancet. 2022;399(10324):518. [PMID:35123689]
- DePaulo JR and Horowitz L, Understanding Depression, Wiley Press, 2002.
- DeRubeis RJ, Zajecka J, Shelton RC, et al. Prevention of Recurrence After Recovery From a Major Depressive Episode With Antidepressant Medication Alone or in Combination With Cognitive Behavioral Therapy: Phase 2 of a
2-Phase Randomized Clinical Trial. JAMA Psychiatry. 2020;77(3):237-245. [PMID:31799993]
- Delgadillo J, Ali S, Fleck K, et al. Stratified Care vs Stepped Care for Depression: A Cluster Randomized Clinical Trial. JAMA Psychiatry. 2022;79(2):101-108. [PMID:34878526]
- Folstein MF, Romanoski AJ, Nestadt G, et al. Brief report on the clinical reappraisal of the Diagnostic Interview Schedule carried out at the Johns Hopkins site of the Epidemiological Catchment Area Program of the NIMH. Psychol Med. 1985;15(4):809-14. [PMID:4080884]
- Mondimore FJ, Depression: The Mood Disease, 4th Edition, Johns Hopkins Press, 2013
- O'Connor EA, Whitlock EP, Beil TL, et al. Screening for depression in adult patients in primary care settings: a systematic evidence review. Ann Intern Med. 2009;151(11):793-803. [PMID:19949145]
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How do you treat MDD with psychotic features?
Treatment usually involves antidepressant and antipsychotic medicine. You may only need antipsychotic medicine for a short period of time. Electroconvulsive therapy can help treat depression with psychotic symptoms.
What drugs are used to treat psychotic depression?
There are a number of antipsychotic, or neuroleptic, medications commonly used today. These include aripiprazole (Abilify), asenapine (Saphris), cariprazine (Vraylar), olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal).
How do you treat psychotic features?
medicine – a combination of antipsychotics and antidepressants can help relieve the symptoms of psychosis. psychological therapies – the 1-to-1 talking therapy cognitive behavioural therapy (CBT) has proved effective in helping some people with psychosis.
What is one effective treatment for major depressive disorder?
Medications and psychotherapy are effective for most people with depression. Your primary care doctor or psychiatrist can prescribe medications to relieve symptoms. However, many people with depression also benefit from seeing a psychiatrist, psychologist or other mental health professional.