Major depression with psychotic features

Psychotic major depression (PMD) is a type of depression that can include symptoms and treatments that are different from those of non-psychotic major depressive disorder (NPMD). PMD is estimated to affect about 0.4% of the population (or one in every 250 people). Note that roughly 25 percent of people who are admitted to the hospital for depression suffer from what's called psychotic depression.

Psychotic depression is characterized by not only depressive symptoms, but also by hallucinations (seeing or hearing things that aren’t really there) or delusions (irrational thoughts and fears). Often psychotically depressed people become paranoid or come to believe that their thoughts are not their own (thought insertion) or that others can ‘hear’ their thoughts (thought broadcasting).


Currently, PMD is considered a severe form of major depression, but patients with mild or moderate depression may still have psychotic features. Many people with PMD experience delusions, which are beliefs or feelings that are untrue or unsupported.

Paranoid delusions or delusions of guilt may be the most common psychotic symptoms in PMD. Patients with PMD often have concerns that people are paying special attention to them or are trying to persecute them. Patients who experience delusional guilt may believe that they are being punished for past misdeeds or are responsible for problems they couldn’t possibly be responsible for.

Other common delusions include those in which people are concerned that something is terribly wrong with their bodies and physical health, when actually there isn’t anything wrong. Unlike other psychotic disorders, the delusions in PMD may not be very obvious. Delusions appear to be more common than hallucinations in PMD, but some people with PMD do hallucinate, or see or hear things that others do not. Auditory hallucinations (sounds) are perhaps the most common hallucinations seen in PMD. While other patients may report seeing, touching or smelling things that are not there, it is less common.

Other symptoms that are common in PMD are agitation, difficulty falling asleep, and frequent waking during the night. In addition, patients with PMD may have a greater suicide risk than patients with NPMD. Finally, those with PMD may have greater cognitive deficits (e.g., memory problems) than those with NPMD.

Diagnostic criteria

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), a widely used manual for diagnosing mental disorders, patients who show at least six of the following symptoms in a period of two weeks may be diagnosed with PMD. In order to qualify for a PMD diagnosis, patients need to report either (1) or (2), and (10), along with three or four other symptoms (for a total of six). These symptoms also must be different from how patients felt or behaved at a previous time.
  1. Depressed mood most of the day nearly every day.
  2. Loss of interest or pleasure in all, or almost all, activities most of the day nearly every day.
  3. Significant weight loss or weight gain, OR decrease or increase in appetite nearly every day.
  4. Insomnia OR hypersomnia (sleeping excessively) nearly everyday.
  5. Psychomotor agitation (moving more quickly) OR retardation(moving more slowly) nearly every day, so much that other people notice.
  6. Fatigue OR loss of energy nearly every day.
  7. Feelings of worthlessness OR excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  8. Diminished ability to think or concentrate, OR indecisiveness, nearly every day.
  9. Recurrent thoughts of death (not just fear of dying), recurrent ideas about suicide without a specific plan, or a suicide attempt or specific plan for committing. suicide
  10. Presence of psychosis (hallucinations/delusions).
Causes of Psychotic Depression

As is the case with other forms of depression, the exact causes of psychotic depression are not known. Research does however suggest that hereditary factors and a history of other depressive conditions such as bipolar disorder often play a role in susceptibility. In addition, abnormal levels of hormones in the bloodstream may also aggravate the onset of psychotic depression.

Psychotic depression is frequently associated with high levels of a hormone called 'cortisol' in the blood. (Cortisol is a hormone produced by the adrenal cortex. High levels of cortisol have been associated with stress.)

Treatment of Psychotic Depression

Treatment for psychotic depression requires a longer hospital stay and close follow-up by a mental health professional. Combinations of tricyclic antidepressants and antipsychotic medications have been most effective in easing symptoms. The addition of lithium to this combination can be beneficial for those with bipolar disorder. Electroconvulsive therapy is very effective for this condition, but it is generally a second line treatment.

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

Prognosis of Psychotic Depression

Treatment is very effective for psychotic depression and people are able to recover, usually within a year, but continual medical follow-up may be necessary. Generally, the depressive symptoms have a much higher rate of recurrence than the psychotic symptoms. It is important, however, that a person experiencing these symptoms be properly diagnosed because treatment is different than for other major depressive illnesses and risk of suicide is greater.

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