Psychotic depression is a specific subtype of major depression that includes primary features of depression and psychotic symptoms like delusions and hallucinations.

One of the most severe mood disorders, psychotic depression can be difficult for both those with the condition and the people who love them. While psychotic depression can be challenging to cope with, understanding what separates it from other forms of depression, being able to recognize signs of the condition and learning about factors that can put people at risk of developing it can help individuals seek treatment sooner rather than later.

What Is Psychotic Depression?

Psychotic depression is typically defined as a condition that shares features of both depression and psychosis. Psychotic depression is generally accepted as a specific subtype of unipolar major depression. Features of severe psychotic depression include delusions, hallucinations or breaks with reality.

Distinguishing Psychotic Depression From Major Depression

All forms of depression can be characterized as mood disorders and involve persistent feelings of sadness. Major depression, also referred to as clinical depression or non-psychotic depression, affects how a person processes information, feels and behaves. These symptoms can lead to pronounced emotional and physical problems that can disrupt daily activities.

Major depression with psychotic features includes the additional characteristic of psychosis. Psychosis is a psychological phenomenon characterized by temporary delusions, hallucinations, and breaks with reality. Although a common belief is that psychotic depression is simply a severe form of major depression, the connection between depression severity and the presence of psychotic symptoms is weak.

Psychotic depression statistics or prevalence within the general population worldwide has been increasing over the last two decades, with a current lifetime risk of 20–25% in women and 7–12% in men, although this gender difference may be due, in part, to a greater tendency in women to seek help. Some studies have found that approximately 18% of people who meet the criteria for major depression also had psychotic features.

Symptoms of Psychotic Depression

Psychotic depression symptoms include all of the primary defining symptoms of depression, such as:

  • Persistent feeling of sadness
  • Loss of appetite
  • No longer enjoying activities that were previously enjoyable
  • A general loss of interest in life

However, psychotic depression additionally includes symptoms of psychosis, which could include breaks from reality, like visual or auditory hallucinations, and disruptions in ideation, like believing others could hear or control their thoughts.

More specifically, a person with psychotic depression may:

  • Have inappropriate emotional outbursts, like yelling at a coworker for a trivial issue
  • Neglect their personal hygiene and appearance
  • Spend an inordinate amount of time sleeping or being by themselves
  • Have conversations that might appear to be nonsensical

Psychotic depression experiences have a wide range of variability, which makes them difficult to summarize. However, individuals experiencing psychotic depression are far more likely to answer “yes” to questions like:

  • Do you ever feel as if you are possessed by someone or something else?
  • Do you ever feel as if all things in magazines or on TV were written especially for you?
  • Do you ever think that people can communicate telepathically?
  • Have your thoughts ever been so vivid that you were worried other people would hear them?

Psychotic Depression vs. Schizophrenia

People with psychotic depression and schizophrenia experience psychosis. However, the psychosis experienced by people with psychotic depression is generally related to the primary condition of depression, which is a mood disorder. That is, they are related to feelings of sadness, failure and negative self-image.

Importantly, the psychosis experienced by people with psychotic depression only occurs during episodes of major depression. People with psychotic depression are often aware of their symptoms and might feel ashamed of them and consequently, leading them to try to conceal their condition from others.

Those with schizophrenia have powerful hallucinations, delusions and disrupted thought processes, but these are not related to mood and are often implausible or completely unintelligible. They also tend to exhibit disrupted motor behavior, such as:

  • Unusual body posture
  • Slowed movement patterns
  • Rigid or involuntary movement patterns
  • Catatonia

Risk Factors for Psychotic Depression

What causes psychotic depression? In general, depression can be the result of imbalances in brain chemistry, hormone levels and inherited traits and may be triggered by negative life circumstances. Factors that are associated with an increased risk of depression include personality traits like:

  • Pessimistic worldview
  • Self-loathing
  • Low self-esteem

Further, traumatic life events can trigger depression, including:

  • Financial and relationship problems
  • Physical or sexual abuse
  • Loss of a job or loved one

There is also a strong genetic link to depression. This connection extends to relatives that have a history of depression, bipolar disorder and chemical addiction. In some cases, certain medications for high blood pressure or insomnia have also been associated with depression.

Parental history of bipolar disorder appears to be a strong risk factor for the development of psychotic depression, whereas this does not appear to be a factor for non-psychotic depression. However, it is important to understand that there is a high degree of overlap between risk factors associated with psychotic and non-psychotic depression and these same risk factors are associated with a wide range of other mental disorders.

Diagnosing Psychotic Depression

A psychotic depression diagnosis is difficult because psychotic depression shares many symptoms with other mental disorders like schizophrenia and bipolar disorder. A clinical diagnosis of psychotic depression requires the observation of multiple psychotic episodes that co-occur with multiple features of major depression. Only mental health professionals have the training to properly administer a psychotic depression test.

The test includes blood or urine tests to rule out other physical problems and the collection of a full medical history and family history to assess for genetic risk indicators.

Many other cognitive and behavioral factors are also considered, including:

  • Recurrent thoughts of death or suicide
  • Depressed mood
  • Loss of interest in previously pleasurable experiences
  • Sleeping too much or too little
  • Difficulty thinking, concentrating or making decisions
  • Identifying delusions and hallucinations.

It is important to note that the psychotic depression test is often made more difficult by the person’s desire to hide their symptoms.

Psychotic Depression Treatment and Prognosis

Depression is a treatable mental illness. Perhaps the most important factor for treatment is the realization that major depression is a biological impairment that can be difficult to overcome by simple lifestyle changes. However, even the most severe cases of depression can be effectively treated with psychotherapy, medications or a combination of the two. In cases where these therapies prove ineffective, electroconvulsive therapy or other brain stimulation therapies may be effective.

Research specifically concerning psychotic depression is not as advanced as research with major non-psychotic depression. However, some research suggests that a cocktail of antidepressants and antipsychotics appears to be more effective than monotherapy with antidepressants or antipsychotics alone.

Related Topic: Psychosis treatment

If you or a loved one struggle with depression and co-occurring substance use disorder, The Recovery Village can help. You can receive comprehensive treatment from one of our facilities located throughout the country. To learn more about treatment programs, call The Recovery Village to speak with a representative.

Megan Hull
Editor – Megan Hull
Megan Hull is a content specialist who edits, writes and ideates content to help people find recovery. Read more
Dr. Karen Vieira
Medically Reviewed By – Dr. Karen Vieira, PhD
Dr. Karen Vieira has a PhD in Biomedical Sciences from the University of Florida College of Medicine Department of Biochemistry and Molecular Biology. Read more

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The Recovery Village aims to improve the quality of life for people struggling with substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare providers.