What Is Psychotic Depression?

Are you at risk and, if so, what can you do about it?

She's reached the end of her rope!
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Some people with severe depression also experience psychosis in addition to the usual symptoms of depression, such as depressed mood, appetite changes, and loss of interest in activities previously enjoyed. Psychosis is a condition in which a person begins to see and hear things that aren't really there (hallucinations) or experience false ideas about reality (delusions). There may also be disorganized or disordered thinking.

When psychosis occurs alongside depression, it is called psychotic depression.

Who Will Develop Psychotic Depression?

It is estimated that about three percent to 11 percent of all people will experience severe depression during their lifetime. Of those who experience severe clinical depression, about 10 percent to 15 percent will develop psychotic depression. It is, however, impossible to predict the exact people who might be prone to psychotic depression, as not enough is known about the condition's causes. In addition, the definitions and measurement tools for depression are always changing, meaning that these statistics are always shifting.

From what we know now, some of the factors that may make you more prone to depression in general include:

  • Having a parent or sibling with depression. A propensity toward depression, especially severe depression, tends to run in families. If you have a parent or sibling who has had depression, you are more likely to develop it yourself.
  • Being a woman. Women are twice as likely as men to develop depression; about two-thirds of those who develop severe depression are women.
  • Having a difficult childhood. People who experienced adversity as children are more predisposed to depression.

What Is Believed to Cause Psychotic Depression?

One theory is that a particular combination of genes must be inherited in order for a person to develop psychotic depression.

Certain genes might be responsible for depression symptoms while others might be responsible for the psychotic symptoms, making it possible for an individual to inherit a genetic vulnerability to depression, psychosis, or both. This theory would explain why not all people with depression develop psychosis.

Another theory is that high levels of the stress hormone cortisol could be involved. High levels of cortisol are often found in people with depression.

What Are Its Symptoms?

A person with psychotic depression will, first of all, experience a combination of depression symptoms, potentially including:

  • depressed mood
  • diminished interest or pleasure in activities previously enjoyed
  • significant changes in weight and appetite
  • sleep difficulties
  • fatigue or lack of energy
  • feelings of worthlessness or guilt
  • inability to concentrate
  • thoughts of death or suicide

In addition to the above symptoms, patients with psychotic depression will also experience delusions and/or hallucinations.

How Is Psychotic Depression Diagnosed?

At present, psychotic depression is not considered a separate illness.

Instead, it is considered to be a sub-type of major depressive disorder. In order to be diagnosed with psychotic depression, a person must first meet the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders for major depressive disorder. In addition, the person must exhibit signs of psychosis, such as hallucinations and delusions.

An evaluation by a physician might also include testing to rule out other potential causes for the patient's psychotic symptoms, such as drugs.

How Is It Treated?

Psychotic depression is usually treated in a hospital, using antidepressant and antipsychotic medications. When depression symptoms are severe, electroconvulsive therapy may be used to bring about rapid relief. Ongoing treatment will include medications to prevent a recurrence of symptoms.


American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Washington, DC: American Psychiatric Association, 1994.

Jacobson, James L. and Alan M. Jacobson. Psychiatric Secrets. 2nd Ed. Philadelphia: Hanley & Belfus, Inc., 2001.

Parker, George F.  "DSM-5 and Psychotic and Mood Disorders."  The Journal of the American Academy of Psychiatry and the Law.  42 (2014):  182-90.

Stern, Theodore A. et. al. eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st edition. Philadelphia, Mosby, Inc, 2008.

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