Major Depression with Psychotic Features

Major depression is a serious mental health condition that disrupts functioning and can leave sufferers feeling helpless and overwhelmed by even the simplest tasks or responsibilities. Individuals with depression lose energy and motivation, and they experience feelings of emptiness and meaninglessness that won’t relent.

As debilitating as the symptoms of clinical depression can be, the situation is even worse for people who suffer from a related condition known as psychotic depression, or major depression with psychotic features. People with this disorder experience the symptoms of depression and psychosis simultaneously, a potent and highly disabling mixture.

When major depression is complicated by psychotic symptoms, professional assistance should be sought immediately. Unfortunately, because psychotic depression is still relatively unknown outside the mental health profession, few people suspect they or their family members may be suffering from its dangerous effects.

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Psychosis is a severe brain-related condition that causes sufferers to lose touch with reality. Their perceptions become distorted and their inner experiences no longer reflect the world as it actually is, and they may go through enormous emotional and psychological upheaval as they struggle to maintain healthy relationships and meet their personal and professional obligations.

In the early stages of psychosis, family members and friends will likely notice only small changes in their loved ones’ behavior, such as:

• A loss of focus and concentration
• Discomfort around and mistrust of other people
• A sudden desire to be alone or isolated
• Poor performance in school or on the job
• A loss of interest in personal care or hygiene
• Sometimes frightening emotional outbursts, seemingly unconnected to any obvious cause
• A lack of emotion or demonstration of feelings (which may alternate with emotional outbursts)

As these symptoms intensify, individuals may eventually cross the line into full-blown psychosis, where hallucinations and delusions seriously interfere with their ability to function.

These false sensory impressions and false beliefs often take on a sinister or threatening aspect, and they can cause sufferers to make bizarre statements or exhibit irrational and possibly hazardous behaviors. Others may very well be at risk because of these behaviors, and people experiencing psychotic episodes are certainly not safe and should not be left unsupervised until medical attention can be obtained.

Psychosis is not in itself a true medical condition. Rather, it is a symptom of a deeper medical problem. It will not clear up on its own, and a period of hospitalization might be necessary when the symptoms of psychosis reach their peak intensity.

Major depression is the most prevalent form of mental illness in the United States, and psychosis is a more common side effect of depression than most realize:

• About 3 percent of Americans will have a psychotic episode at some point in their lives.
• A large-scale study sponsored by the National Institute of Mental Health (NIMH) found that 14.7 percent of people suffering from major depression had a history of psychotic symptoms.
• In one study of patients admitted for hospitalization for depression, 25 percent met the diagnostic criteria for psychotic depression.
• Among patients over age 60 hospitalized for depression, up to half will suffer from psychotic depression.
• According to one research study involving patients diagnosed with psychotic depression, 27 percent were originally misdiagnosed, usually with conventional depression or bipolar disorder.

Advanced psychotic symptoms can occur in conjunction with depression, bipolar disorder (in the depressive or manic state), schizophrenia, or schizoaffective disorder, or as an occasional symptom of other conditions like dissociative identity disorder, PTSD, schizotypal personality disorder, and borderline personality disorder. In every instance it is a complication that will make the symptoms of the associated mental health disorder more serious and debilitating, making treatment an urgent priority.

Psychotic features that accompany depression may produce mood-congruent or mood-incongruent symptoms.

This means that the delusions and hallucinations experienced may either complement the negative mindsets associated with depression (mood-congruent) or contradict or counteract them (mood-incongruent) by convincing the sufferer that he or she is powerful, important, or invincible. Mood-incongruent psychosis seems to mimic the manic states of bipolar depression, while mood-congruent intensifies the sense of emptiness and desperation associated with major depression.

The hallucinations experienced by people with psychotic depression may be audio (hearing voices), visual, touch- or smell-related, and are usually so lifelike that sufferers cannot tell the difference between imagination and reality. These hallucinations may be filled with ominous warnings and content and are often highly personalized and meaningful to the psychotic depression sufferer. Delusions can cover a wide variety of unusual or paranoid thoughts and beliefs, and they can easily motivate actions that are self-destructive or put others at risk.

The symptoms of psychotic depression are nearly identical to those of conventional clinical depression. Common signs include:

• Fatigue and lack of energy
• Loss of motivation
• Sleep disturbances
• Loss of ability to take pleasure in formerly enjoyable activities
• Declining performance in work or at school
• Inability to initiate or finish tasks
• Social isolation, preference for solitary activities
• Constant expressions of pessimism, negativity, and cynicism
• Talk of suicide

Psychotic depression does produce a few additional symptoms that may not normally manifest in those with depression alone. Sufferers tend to experience more agitation and anxiety than people with conventional major depression, may worry constantly about their physical health, can experience escalating difficulties with thinking and memory, and at times may sit or lay in the same position for hours, without moving or speaking to anyone.

When their delusions or hallucinations run out of control, people suffering from major depression with psychotic features may become completely disconnected from reality, and at that point emergency medical intervention is required.

All forms of mental illness can be traced to brain abnormalities (both chemical and structural) that inhibit clear thinking and perception and cause overstimulation in neural centers that impact mood and behavior. In men and women with psychotic depression, weak or uncoordinated activity in the hypothalamic pituitary adrenal axis (HPA) appears to play an influential role in the onset of the condition.

The HPA is a neurological feedback network that unites the hypothalamus and pituitary gland in the brain with the adrenal gland near the kidneys. When the system operates smoothly, it helps facilitate normal reactions to stress, boosts immune function, promotes a balanced mood, regulates emotional responses, and aids the process of digestion.

However, medical studies indicate that dysfunctionality in the HPA is common among people with psychotic depression, which results in chronically elevated levels of the hormone cortisol, a potent chemical normally released in limited amounts in response to stress. Overabundance of cortisol indicates a high vulnerability to stress and anxiety, and that can ultimately leave a person vulnerable to depression and/or psychosis.

The established risk factors for major depression with psychotic features include:

• Family history of mental illness and/or psychosis. This is the most statistically significant predictor of future psychotic depression.
• Social isolation. Being single, living alone, having had no serious relationship, and lacking friends or close confidantes all increase the chances that a person will develop psychotic depression.
• Brain injuries or diseases. Having brain tumors, a history of concussions, strokes, or brain diseases like Alzheimer’s, dementia, or Parkinson’s can leave someone vulnerable to psychosis, either with or without depression.
• Substance abuse. The longer the abuse, and the more powerful and addictive the drugs, the greater the risk for psychosis or any other type of mental health disorder, including depression.
• Exposure to trauma in adulthood. Being a victim of violence or exploitation, or witnessing it, can significantly increase a person’s chances of developing psychotic depression.
• Childhood abuse. People who were subjected to physical, sexual, or emotional abuse as children have an elevated risk for severe, life-altering mental health disorders.

Since most depression sufferers don’t exhibit psychotic symptoms, they can be easy for clinicians to miss if the patient doesn’t report them in detail. An excessive focus on either the symptoms of depression or the symptoms of psychosis can also lead to an incomplete diagnosis.

But these types of errors are becoming increasingly rare. Awareness of the existence of psychotic depression has grown as research into the condition has progressed.

To be diagnosed with psychotic depression, a patient must display multiple symptoms of depression for at least two weeks, and the distinctive symptoms of psychosis—namely, delusions and/or hallucinations—must also have been experienced during that time period. These standards are codified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which lists major depression with psychotic features as a subtype of major depression.

Patients may be diagnosed with either mood-congruent or mood-incongruent psychotic depression, but this will not alter recommendations for treatment.

While aftercare will include outpatient services, treatment for psychotic depression should begin in a residential mental health facility that offers intensive inpatient programs for individuals with severe psychological or behavioral health issues.

Before treatment can begin, a patient showing signs of psychosis should be thoroughly evaluated by a mental health professional (and possibly by a medical doctor as well) to determine if their symptoms are severe enough to require psychiatric hospitalization.

Long-term inpatient treatment for psychotic depression will consist primarily of medication plus daily individual therapy sessions, with group and family sessions added as recovery progresses. Studies have confirmed that a combination of antidepressants and antipsychotic medications delivers the strongest healing effects for those who suffer from this disorder, although ECT (electroconvulsive or electroshock) therapy may occasionally be offered if the patient does not respond adequately to medication.

Psychotic depression is a challenging condition to overcome. But there is great hope of eventual recovery for sufferers who begin treatment in an extended inpatient program, are truly dedicated to their healing process from initial treatment through aftercare, and have the full and unconditional support of family and friends at each stage of their recovery.

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