While major depressive disorder is common, affecting an estimated 10 percent of people at some point during their lives, the combination of depression and psychotic experiences is, according to research, fairly rare, affecting no more than a few in every hundred people with clinical depression. Misdiagnosis may play a large part in this, however, as an alarming bit of research revealed that 65 patients who later turned out to have psychotic depression initially received a total of 130 incorrect diagnoses between them, ranging from major depressive disorder without psychotic features to generalized anxiety disorder and substance abuse.
Although the exact causes of psychotic depression haven't yet been pinpointed, brain chemistry, a family history, and exposure to severe stress are all thought to contribute.
What are the symptoms of psychotic depression?
Clinically depressed people will experience symptoms like:
- A depressed mood — feeling low, empty, pessimistic, and sad
- Losing interest in things that used to be important, whether things like work or socializing, or getting out of bed and having a shower
- Losing appetite and weight, or increased appetite and weight gain
- Feeling guilty and worthless
- Not being able to sleep well, or oversleeping
- Trouble concentrating and difficulty making decisions
- Thoughts about death — these can include suicidal feelings, suicide plans, or a suicide attempt
Psychosis, on the other hand, involves hallucinations, delusions, or both:
- Hallucinations means you see, hear, or feel things that aren't there — hearing voices (which can be kind or troublesome), feeling like something is crawling on you, or seeing yourself immersed in a flood even though one isn't happening are some examples.
- Delusions are persistent beliefs in things that aren't true, despite ample proof to the contrary. Examples might include thinking the person's neighbors are plotting to kill them, believing other people can hear their thoughts, or being convinced their loved ones will have an accident because of something they did.
How is psychotic diagnosis diagnosed?
Having spoken to people who have suffered from either psychotic depression or psychosis, it became clear that folks currently enduring psychotic experiences are often aware that that are psychotic, especially if this isn't their first episode — something that counters popular belief, I'd say. Though the voices that are often part of hallucinations sound real, for instance, people who find themselves in an empty room often still deduct that they can't be. The diagnostic process may start, then, with the patient themselves knowing something is very wrong, and seeking help. It may also begin with loved ones being worried about the person's behavior seeking help, often because they're aware their friend or relative could pose a serious danger to themselves. People in this situation may be extremely conflicted about what to do, but if you look at your involvement as caring for someone who is currently unable to do that for themselves, it may be easier for you.
The diagnostic process itself depends on a diagnosis of depression in which psychotic features are also present. Doctors may conduct a physical exam and even do some lab tests to rule out physical causes, and then look at the symptoms. Loved ones' observations may be asked for during this process.
Treatment for psychotic depression
Being fairly rare, researchers readily acknowledge that psychotic depression and its treatment are grossly understudied. This, unfortunately, means that no medications are currently FDA-approved specifically for the treatment of depression with psychotic features. Having said that, existing research leaves us with a fairly obvious conclusion — that psychotic depression should be treated with a combination of antidepressants and antipsychotic medications, and that this combination is better than either of those on their own.
These medications may include an antidepressant from the selective serotonin reuptake inhibitor class (SSRIs) — examples are fluoxetine (Prozac) and sertraline (Zoloft) — and antipsychotics like quetiapine (Seroquel) or risperidone (Risperdal). Because they usually take a while to "kick in" and the patient may pose a significant danger to themselves in the meantime, the treatment is likely to be administered in an inpatient setting.
On the upside, once given the right treatment, people with psychotic depression often improve extremely quickly. Once this happens, talk therapy can be added to the treatment protocol and electoconvulsive treatment is another option.