Psychotic Depression: Symptoms and Treatment

Overview

Psychotic depression (major depression with psychotic features) is one of the most severe forms of the general depressive disease, in which the person experiences occasional moments of delusional or paranoid being. Psychotic depression is characterized by not only depressive symptoms, but also by hallucinations (seeing or hearing things that aren't really there) or delusions. Psychotic depression is a chronic, cyclic condition. In general, the patient may have unremarkable general depressive episodes marked by moments of extreme psychoses. Suicide is most prevalent in patients affected by psychotic episodes. Psychotic depression is unlike schizophrenia because people who are experiencing this type of depression are usually aware that the psychotic episodes they experience are not real.

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Diagnosing

Though major depression with psychotic features represents about 25% of consecutively admitted patients, it is frequently overlooked by professionals. Patients are often reluctant about revealing cognitive deficits and delusions and will sometimes deny thoughts of suicide, which makes this disorder difficult to diagnose. Similarities in the symptoms of psychotic depression, schizophrenia, and schizoaffective disorder also make diagnosis even more difficult.  Clinical data have shown that in multiple cases psychotic depression as much more in common with schizophrenia than with non-psychotic depression.

In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, psychotic depression is classified as a major depressive disorder, severe, with psychotic symptoms. This classification requires the usual criteria for a major depressive episode with the additional symptoms of hallucinations or delusions, which can be either mood-congruent or -incongruent. Some researchers have argued that psychotic depression should be classified as a separate clinical disorder due to a number of biological and behavioral symptoms that are specific for this depression type of disease.

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While symptoms of psychotic depression can be intense, differentiation from other disorders and detection of undisclosed symptoms often require extensive examination of the patient. The delusions experienced by psychotically depressed patients are typically guilty, paranoid, and somatic; and their hallucinations are auditory, visual, or somatic. Studies conducted to test the neuro-vegetative symptoms of psychotic depression revealed multiple symptoms of severe depression and permanent depressive state of mind with both higher levels of retardation and higher levels of cognitive disturbance according to Hamilton Rating Scale for Depression (HAM-D) scores and compared with non-psychotic patients.

Patients with psychotic depression have shown a higher rate of errors of commission on verbal memory tests. Researchers found that these patients had a higher rate of cluster A personality disorder and a lower level of education compared with patients with non-psychotic depression.

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Other features characteristic of psychotic depression compared with non-psychotic depression include a history of past delusions but fewer previous episodes, a positive family history of mental disorder, previous suicide attempts, greater suicidal ideation and intent. Psychotic depression is often considered a disorder of the elderly, but at least one study has reported that younger age was found to be a more common characteristic of psychotic rather than non-psychotic depression. In comparison with patients with schizophrenic disorders, patients with psychotic depression have shown greater emotional impact features and higher tendency to lose control.  If a patient’s psychotic depression is further complicated by agitation, determining whether the patient is suffering from agitated psychosis, severe anxiety, or a dysphoric manic state may be difficult. A number of questions can help in the differential diagnosis:

  • Does the patient suffer from insomnia?
  • If so, does the patient believe that he or she needs less sleep than usual?
  • If delusions are present, are they guilt-ridden as in a depressive state or pleasure-seeking as in a hypomanic or manic state?
  • Has the psychosis been present in the absence of affective symptoms?
  • Is there a family history of psychotic or affective illness?
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Treatment

An individual suffering from psychotic depression needs to be hospitalized as this disease only responds to intensive treatment. Hospitalization also ensures that the patient is under proper medical observation. The treatment for this form of depression can be divided into two parts; medication and electro-convulsive treatment.

As far as medication is concerned the treatment is mostly dependent on antidepressant and antipsychotic drugs. There are various antipsychotic or neuroleptic drugs available today but these have to be used under strict medical supervision as they have some side-effects.

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Electro convulsive therapy (ECT) is recommended if the medications don't yield the desired result. In ECT, electric current is applied by putting electrodes on the scalp of the patient. It causes controlled convulsions and triggers massive neurochemical release in the brain. It mostly lasts for 30 to 90 seconds and this method is practiced for 6 to 10 times. It is carried out under the influence of anesthesia to ease the pain. Although that is one of the accepted fastest ways to relieve the patient, its most common side effect is temporary short term memory loss.

Researchers are also studying the effectiveness of RU-486 (the "abortion pill" and "emergency contraceptive"), which is said to dramatically relieve psychotic depression.

It is observed that, like all other forms of depression, even psychotic depression may eventually increase the risk of suicides. Hence a proper solution to this problem is a must, and combination treatment in the form of medications, counseling and talk therapies would definitely help the individual.

Prognosis

If you have symptoms of depression combined with hallucinations or delusions, don't hesitate to ask for help. It is particularly important to share the details of your symptoms with your doctor, because psychotic depression must be managed differently than other types of depression. The most serious risk of psychotic depression is suicide, so getting appropriate treatment as soon as possible is crucial.

Psychotic depression is an illness, not something to be ashamed of or a weakness. It is also a treatable condition, and most people recover within a year, however continual medical follow-up may be necessary.


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