Can Major Depression Cause Psychosis? Recognizing and Treating Psychotic Symptoms

Although psychotic symptoms of depression are under-recognized, it is believed that approximately 20% of people with major depression will experience such symptoms during the course of their illness. These symptoms arise directly from the depression itself rather than as the result of a psychotic disorder such as schizoaffective disorder and generally represent a severe articulation of major depression. As such, psychotic depression is not a distinct diagnosis, but a subclassification of major depressive disorder.

The presentation of hallucinations and delusions in psychotic depression are distinct from those experienced by people with primary psychotic disorders in a number of important ways. One of the most critical distinctions is timing. For people with psychotic depression, depression precedes psychosis—and psychosis arises only in the presence of that depression.

“In depression with psychotic features, patients generally have a history of previous depressive episodes, and the current episode begins with classic depression that worsens over time, at which point psychotic symptoms emerge,” explains Dr. Albert H. C. Wong, Professor of Psychiatry at the University of Toronto. Conversely, if people with schizophrenia become depressed, they tend to do so only after psychotic episodes, when they gain the clarity to “realize the poor prognosis, loss of function, and dependence on caregivers.” In cases of schizoaffective disorder, on the other hand, mood episodes and psychotic episodes must occur both simultaneously and independently of each other, rather than solely occurring together.

The specific qualities of hallucinations and delusions experienced by people with psychotic depression also differ from those experienced by people with primary psychotic illnesses:

• Often, psychotic symptoms are mood congruent, such as delusions that they will cause something bad to happen, that a loved one will die, or that their partner will leave them.
• Auditory hallucinations often involve messages that they are a bad person, or even that they should kill themselves.
• Some people also experience somatic hallucinations, such as putrid bodily smells resulting from undiagnosed medical conditions.

In such cases, psychosis tends to be an extension of depression, rather an indication of a primary psychotic disorder.

While all forms of severe depression can have a significant impact on quality of life and complicate prognosis, psychotic depression presents heightened risks. Grace Rattue writes, “The course of the disorder is linked to elevated rates of relapse and higher long-term psychosocial impairment, as well as higher mortality rates than [people with non-psychotic depression].” Although this can be explained in part due to the fact that people with psychotic depression tend to be clustered in the more severe end of the depression spectrum, it may also be attributed to the unique symptomatology of psychotic depression.

Psychotic symptoms can be deeply disturbing and functionally disruptive, impairing the ability to participate in positive, meaningful social relationships and vocational activities. People with psychotic depression are also more likely to experience symptoms such as rumination, insomnia, psychomotor disturbances, and cognitive dysfunction than people with non-psychotic depression, further compromising emotional wellbeing and functional ability. Additionally, psychotic depression is associated with a higher risk of developing bipolar disorder.

Unfortunately, psychotic depression frequently goes undiagnosed. While many families worry that their loved one with psychotic depression will be incorrectly diagnosed as having a primary psychotic disorder such as schizophrenia, data shows that clinicians are far more likely to overlook the psychotic features of the illness altogether. According to data from the National Institute of Mental Health Study of the Pharmacotherapy of Psychotic Depression, “27% of 130 diagnoses among a well-characterized sample of patients with a research diagnosis of psychotic depression were initially incorrectly diagnosed.” The vast majority of those were misdiagnosed as major depressive disorder without psychotic features.

Researchers point out that this rate of incorrect diagnosis is likely far lower than what would be found in in the general population, as patients with complex medical histories that could complicate diagnosis (such as a recent history of substance abuse) were excluded. “This finding suggests that the clinicians were missing the psychosis rather than the mood disorder,” says Anthony Rothschild, Professor of Psychiatry at the University of Massachusetts Medical School.

The widespread under-recognition of psychotic features in major depression may be the result of a variety of factors, including:

• Reluctance on the part of the client to disclose psychotic experiences out of fear or shame;
• The client failing recognize that what they are experiencing is a form of psychosis in the first place;
• Clinicians failing to ask clients directly about psychotic symptoms, or failing to explain what constitutes psychosis in a way that allows the client to identify their symptoms as psychotic;
• Clinicians themselves failing to identify symptoms of psychosis due to lack of understanding of the complexities of psychotic depression.

Whatever the reasons, the result is that many people who have major depression with psychotic features do not receive the care they need to heal and remain at heightened risk for poor outcomes.