Major Depressive Disorder: Psychotic Depression
In this article, I will discuss major depression coupled with psychotic symptoms—also known as psychotic major depression (PMD and psychotic depressive disorder (PDD). The good news is that it is one of the rarer forms of depression. The bad news: people still do suffer from depression and psychosis, together. I do have to say, though, that it is not unheard of for people with moderate depression to also experience occasional psychotic symptoms. This is one point that I think most people aren't aware of—even professionals. It makes me wonder how many depressed people have psychotic experiences that go unnoticed by others.
When people hear the term psychotic depression, their minds tend to jump immediately to schizophrenia, bipolar disorder, or schizoaffective disorder. It is most definitely none of these disorders and is an entirely separate problem. Although it may share some of the symptoms of these disorders, it also lacks some of their symptoms. For example, psychotic depression does not include manic episodes as seen in bipolar disorder, but psychotic symptoms can exist in both depressive and manic episodes in bipolar disorder.
True clinical depression is not just about feeling a bit low or fed up. We all can feel sadness from time to time, but most of us will snap out of it or resolve the issue causing it and get on with life. Having suffered with severe clinical depression a number of times, myself, I can tell you that there is a world of difference between feeling “a bit down” and being trapped in a black hole of despair from which there seems to be no escape.
When a person is severely clinically depressed, relationships suffer, day-to-day activities grind to a halt, and work becomes impossible. You feel—that is, if you can feel at all because often, you can be emotionless—like you are in stuck in mud, sinking deeper down until there is nothing of the real you left! This is the kind of depression that needs proper medical and therapeutic intervention—as quickly as possible.
Symptoms of Psychotic Depression
Psychiatrists rely on the symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) to form a diagnosis. Psychotic depression is listed in the DSM under mood disorders as a type of major depressive disorder. Psychiatrists may find it difficult to diagnose because some of the psychotic symptoms are often very subtle and can lead to a misdiagnosis. To further complicate things, some patients may prefer not to mention some of the stranger psychotic symptoms they encounter out of fear and embarrassment.
It is important for psychiatrists to take a thorough look at the patient's history and condition to be sure that the wrong diagnosis isn’t given. Bipolar disorder, schizophrenia, and other psychotic disorders should be eliminated as a diagnosis before reaching the conclusion of psychotic depression.
Here are some of the symptoms a psychiatrist will look for:
- Persistent low mood
- Unexplainable chronic pain
- Unable to make decisions/confusion
- Little or no appetite
- Feeling worthless
- No motivation/immobility
- Thoughts of suicide
Delusions and hallucinations are two distinct symptoms that rule out other depressive disorders. I know a number of people with psychotic depression, and they appear to explain it as a terrible depression but with mental energy!
Delusions and Hallucinations
If you have delusions, you will believe things are true when, in reality, they are not. With severe delusions, you may believe you are being followed, spied on, or that your house is bugged. You may even believe you are of high importance or superior to others, as seen in manic phases of bipolar disorder. The range of delusions differs from person to person, but characteristically, in psychotic depression, they will present as a strong belief of victimization or persecution. Another example is the belief that special messages are being sent to you telepathically, usually through media, with televisions being a common source.
More often than not, your delusions will present in a less obvious fashion. You may believe you are less attractive than you actually are, that you are completely useless, or that you are making bad things happen for yourself and those around you. Some people would regard these more subtle forms as self-consciousness resulting from your depression, but there is a difference between a fleeting thought and one that is persistent and produces high levels of fear and anxiety. These subtle delusions may not be noticed during consultations. However, the delusions of psychotic depression appear to be directly connected to the symptoms of a major depression.
The range of delusions differs from person to person, but the most common is a strong belief of victimization or persecution. These delusions can cause considerable agitation, fear, and anxiety.
Auditory hallucinations are common in psychotic depression and tend to present as a voice, whisper, or mumbling. The voices are usually derogatory and belittling. In more severe cases, they may bring suggestions of blame and self-harm. Again, the range of hallucinations varies from person to person. Visual hallucinations tend to happen less often than auditory hallucinations.
Both delusions and hallucinations can become dangerous, especially when the patient is severely depressed and already has suicidal thoughts. That said, patients can react differently to these psychotic episodes. Some will simply not believe them and shrug them off as a figment of their imagination, while others will become more and more fearful and gain an ever-increasing belief in their suggestive element.
How Is Psychotic Depression Treated?
Prescription medication is generally the first-choice treatment because it has proven effective for the most common cases. For most patients, antidepressants may be enough to treat depression that isn't accompanied by psychosis. Many professionals also consider antidepressants for treatment of depression with psychosis, and this does seem to work for some patients, but for others, a combination of an antidepressant and antipsychotic is necessary.
Note that there are no "miracle drugs"—any medication will take some time to have an effect, and the amount of time, again, varies from person to person. SSRIs (selective serotonin reuptake inhibitors) may take a few weeks for effects to be noticed, and for some patients, the dosage may need to be increased to the highest acceptable dose before results are seen.
Electroconvulsive Therapy (ECT)
As with all medications, antidepressants and antipsychotics have their own side effects, but for someone with severe depression, this is often the least of their worries.
In severe cases, where the symptoms are life-threatening (i.e. the patient has suicidal ideations), electroconvulsive therapy may be used in addition to prescriptions. Basically, while you are under anesthesia, small electrical currents will be passed through your brain to induce controlled seizures. The purpose of ECT is to change the brain chemistry enough to relieve symptoms of psychiatric disorders. It is generally only used when all other treatments have failed or when other treatments aren't practical (i.e. if you cannot take medications).
Psychotherapy can be a useful tool for learning how to manage and react to psychotic elements. This can help dispel some of the fear and anxiety resulting from the intrusive thoughts.
For example, cognitive behavioural therapy (CBT) has been found to work well for psychotic depression. By looking at the thoughts and perceptions you have of yourself and the world, therapists can work with you to change these behaviors or find the cause of these thoughts. .
A form of counselling called acceptance and commitment therapy (ACT) can also be useful. This approach uses mindfulness strategies to guide the patient in examining negative thoughts, feelings, and behaviours that are possibly made worse by personality traits. You would be asked to recognise the negative thoughts and behaviours and then learn to be with them in the moment (acceptance) as they arise. The idea is to prevent the huge emotional reactions that sow the seeds of severe clinical depression. Once you learn to accept the negativity—to understand that they are there but that they can be managed—you can then commit to change and form plan of action to diffuse a build up to severe depression.
Learning how to be mindful is great for everyone, but especially for those who are prone to depression. It is our thoughts and feelings that lead to depression, but more importantly, it is our reactions to them that push us over the edge.
Some Facts About Psychotic Depression
- It is not yet known what the exact causes of psychotic depression are, but it is thought that there may be a genetic predisposition to it. The same can be said for other psychotic conditions; bipolar disorder does tend to run in families.
- It is thought that around 10-15% of people suffering from a severe or major depression will have some psychotic experience.
- Although it is possible to have one isolated episode of severe clinical depression, many go on to have subsequent major depressive episodes, although these can be years apart. As the number of episodes grows, the likelihood of another episode increases.
- Puerperal psychosis or postpartum psychosis is a rare form of psychotic depression, although it is believed to be antagonized by a sudden drop in hormones after having a baby. Apparently, this condition is more likely to occur if you or a family member have a history of bipolar disorder or other psychotic illness.