Detailed 101 Guide on Psychosis

A person suffering from major depression with psychotic features has depression as well as feels a sense of loss or is out of touch with reality (psychosis).

Major depression with psychotic ¹features, also known as psychotic depression, is a severe mental health condition that can have serious consequences if left untreated.

People with this disorder experience the devastating lows of depression as well as the terrifying delusions and hallucinations ²of psychosis, and the symptoms produced by this potent combination are extremely debilitating. Nonetheless, psychotic depression can be managed and eventually overcome with long-term treatment and a strong commitment to recovery.

Major depressive disorder with psychotic features is more common in people with more severe depressive symptoms. It is associated with a worse course of illness and more functional impairment than MDD without psychotic features.

Multiple studies have found that patients with psychotic mood disorders perform significantly worse cognitively than those with nonpsychotic mood disorders in a variety of areas.

About Major Depression

Major depression is a serious mental health condition that interferes with functioning and can leave people who suffer from this feeling helpless and overwhelmed by even the most basic tasks or responsibilities. Individuals suffering from major depression lose energy and motivation, as well as have persistent feelings of emptiness and meaninglessness.

As debilitating as clinical depression symptoms can be, the situation is worse for people who suffer from psychotic depression, also known as major depression with psychotic features. People suffering from this disorder have symptoms of both depression and psychosis at the same time, which is a potent and severely disabling combination.

Major depression symptoms include-

• feelings of extreme sadness, irritability, and anger that persist
• feelings of despair and helplessness
• feelings of inadequacy
• loss of interest in previously enjoyable activities
• alterations in appetite and sleep, such as sleeping too much or too little
• fatigue or general lack of energy
• difficulty remembering things, concentrating, or making decisions
• recurrent thoughts of death and suicide

What is Psychosis?

Psychosis is a serious brain disorder that causes individuals to lose touch with reality. Their perceptions become distorted, and their inner experiences no longer accurately reflect the world as it is. They may experience significant emotional and psychological upheaval as they struggle to maintain healthy relationships and meet personal and professional obligations.

Family members and friends will likely notice only minor changes in their loved one’s behavior in the early stages of psychosis, such as

• loss of concentration and focus
• uncomfortable surroundings and mistrust of others
• an unexpected desire to be isolated or alone
• poor academic or occupational performance
• a loss of interest in hygiene and personal care
• frightening emotional outbursts that appear to be unrelated to any obvious cause
• a lack of emotion or display of emotion (which may alternate with emotional outbursts)

As these symptoms worsen, people may progress to full-blown psychosis, in which hallucinations and delusions impair their ability to function.

These false sensory impressions and beliefs frequently take on a sinister and threatening tone, causing patients to make bizarre statements or engage in irrational and potentially dangerous behaviors. Others may be put in danger as a result of these behaviors, and people experiencing psychotic episodes are not safe. They should not be left alone until medical attention can be obtained.

Psychosis is not a true medical condition in and of itself. Rather, it is a symptom of a more serious medical issue. Hospitalization may be required when the symptoms of psychosis reach their peak intensity.

What is Psychotic Depression?

When a severe depressive illness includes some form of psychosis, a subtype of major depression known as psychotic depression develops.

Hallucinations (such as hearing a voice telling you things like you are worthless), delusions (such as having strong feelings of failure, unworthiness, or having committed a sin), or other disassociation from reality could all be symptoms of psychosis. About one in four hospitalized patients with depression suffer from psychotic depression.

According to the National Institute of Mental Health, a person with psychotic depression is detached from reality. People suffering from psychotic depression may hear “voices.” Or else, they might think odd and absurd things. They might believe that they are under the influence of the devil or that the police are looking for them for a crime they didn’t commit.

Psychosis is also a symptom of other mental illnesses, such as schizophrenia. Psychotic features major depression symptoms. While psychotic symptoms in schizophrenia are more frequently bizarre or implausible and have no obvious connection to a mood state, psychotic symptoms in psychotic depression are more frequently delusions or hallucinations that are consistent with themes of depression.

Additionally, those who suffer from psychotic depression may try to conceal their thoughts because they feel humiliated or ashamed of them. This makes psychotic depression very challenging to identify.

However, a diagnosis of psychotic depression is crucial. Compared to nonpsychotic depression, it requires a different type of treatment. Furthermore, bipolar disorder, which is characterized by recurrent episodes of psychotic depression, mania, and even suicide, is more likely to develop after experiencing one episode of psychotic depression in contrast to nonpsychotic depression.

Psychotic depression vs major depression

Psychotic depression is a subtype of major depressive disorder (MDD) characterized by psychotic symptoms. It is characterized by psychotic symptoms occurring during a depressive episode.

MDD, also known as clinical depression, can have an impact on your mood, behavior, daily life, and physical health.

A typical major depressive episode includes severe symptoms of-

• a persistent low mood or loss of interest in daily life for at least 2 weeks
• four or more severe depression symptoms

Psychosis is not one of the nine major symptoms of depression, and many people with major depressive disorder never experience it.

The most recent of the diagnostic and statistical manual of mental disorders, the 5th edition separates the two, classifying major depression with psychotic features as “Other Specified Depressive Disorder.”

Major depression or depression is always a serious condition. Nonetheless, experts consider major depressive disorder with psychosis to be more serious than depression without psychosis because it is more likely to include:

• melancholic characteristics
• more severe features or symptoms of major depression
• a higher risk of self-harm or suicidal ideation

Diagnosis of depression and psychosis

The clinical diagnosis of psychotic depression is typically categorized as a subset of major depressive disorder in diagnostic manuals. The validity of this is a topic of ongoing discussion in the field of mental health.

According to the 11th edition of the International Classification of Diseases³ (ICD), psychotic depression is the most severe subtype of major depressive disorder.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes psychotic features as a subset of major depression. However, in the DSM-5, psychotic features are not indicators of the severity of the depressive illness or major depression.

Mental health professionals may misdiagnose psychotic major depression with psychotic features and symptoms as another disorder. Other illnesses or mental health conditions that may occur include:

• major depression without psychotic symptoms
• schizoaffective disorder
• not otherwise specified depression
• mood disorder

Lack of awareness of the psychotic characteristics of major depression frequently results in a misdiagnosis. A qualified mental health professional must make the diagnosis of psychotic depression.

These specialists will conduct a physical examination and possibly run blood or urine tests to rule out any additional potential medical issues. The mental health professional will also inquire about the patient’s medical background and symptoms.

The doctor may conduct a manic episodes screening if the patient has a family history of bipolar disorder. A person must experience a major depressive episode with at least five symptoms that last for at least 2 weeks in order to receive a diagnosis of major depressive disorder.

A person must display psychotic features and major depression symptoms in order to be diagnosed with psychotic depression. Psychotic depression is a very serious medical condition that needs to be treated right away. People with psychotic depression have a noticeably increased risk of suicide psychosis than those with nonpsychotic depression due to psychosis.

Symptoms of psychotic depression

If an individual has major depressive disorder and psychosis, they will experience symptoms of psychosis and major depression.

A few of the major depression symptoms include:

• a persistently depressed, sad, empty, or hopeless mood, depressive episodes (some people may believe life is no longer worth living, but others might feel more irritable than sad)
• changes in appetite and weight that are sudden or unexplained
• movement changes, such as increased restlessness or a feeling of being slowed down
• feelings of worthlessness, helplessness, self-hatred, or guilt on a regular basis

Psychosis involves a break or disconnect from reality; people suffering from it aren’t always aware of their symptoms.

Symptoms of psychosis can include:

• Delusions, having false beliefs, or believing things that aren’t always true
• Slowed thoughts, movements, and feelings are examples of psychomotor impairment.
• A state of stupor in which you are unable to move, speak, or respond to your surroundings

Psychotic hallucinations and delusions may include the following:

• despite multiple tests indicating otherwise, believing you have a serious mental illness
• believing in your special abilities
• believing you are a celebrity or a historical figure
• hearing voices that criticize or mock you
• noticing a frightening or threatening animal following you
• paranoia, or an irrational or extreme distrust of other people

Delusions, with or without hallucinations, occur more frequently in people suffering from psychotic depression than in hallucinations alone.

Experts divide severe MDD ⁴with psychotic symptoms into two groups:

1. MDD with mood-congruent psychotic features

The feelings and emotions that frequently accompany depression, such as feelings of guilt, worthlessness, personal inadequacy, and fears of illness or death, are reflected in hallucinations and delusions and are characterized as mood-congruent psychotic features.

2. MDD with mood-incongruent psychotic features

Mood- incongruent symptoms include delusions and hallucinations that clash with the feelings associated with depression. One might have visions of a loved one, hear praises of themselves from others, or smell something enticing.

One might also think that someone is attempting to capture, kidnap, or exert control over their mind. These characteristics are defined as mood-incongruent psychotic features.

While mood-congruent psychosis amplifies the sense of emptiness and desperation connected to major depression or psychotic depression, mood-incongruent psychosis appears to mimic the manic states of bipolar disorder and depression.

Risk factors for psychotic depression

The following include risk factors for psychotic depression:

1. Medical family history: This is the most reliable statistical indicator of psychotic depression.
2. Substance abuse: The risk of psychosis or any other type of mental health disorder, including depression, increases with the duration of abuse and with the strength and addictiveness of the drugs.
3. Brain injuries or diseases: People who have brain tumors, a history of head injuries, or illnesses like Alzheimer’s, dementia, or Parkinson’s ⁵are most prone to developing and usually experience psychosis, whether or not they also experience depression.
4. Social isolation: A person is more likely to develop psychotic depression if they are single, live alone, have never been in a committed relationship, or don’t have friends and close confidants.
5. Childhood abuse: People who experience severe, physical, sexual, or emotional abuse as children are more susceptible to life-altering mental health disorders.
6. Exposure to trauma in adulthood: A person’s likelihood of developing psychotic depression rises significantly if they have experienced or witnessed violence or exploitation.

Treatment for Psychotic Depression

There is some difference in opinion regarding the most effective first-line treatment or first-degree relative and second-line treatment for psychotic depression. Sometimes, patients may face treatment-resistant depression.

A combination of antidepressant and antipsychotic medications, also known as monotherapy or the sole use of antidepressants or antipsychotic medications, is typically used as first-line treatment.

Electroconvulsive therapy (ECT) is typically reserved for second-line treatment, and doctors may turn to this form of treatment if other medications have failed to reduce symptoms. As an additional form of treatment for psychotic depression with psychosis, psychotherapy or talking therapy can also be beneficial to patients.

Effective treatment options include the following-

1. Medication

A psychiatrist may prescribe combinations of antidepressant and antipsychotic medications drugs to begin treatment. Different antidepressants have an impact on various neurotransmitter systems. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine⁶ reuptake inhibitors are common variations of these medications (SNRIs).

In addition to first-or second-generation antipsychotics, doctors frequently prescribe antidepressants as a form of treatment. According to research, taking antidepressants ⁷and antipsychotics together may be more beneficial than taking one of the two drugs.

The following are some antidepressant and antipsychotic combination therapies:

• Venlafxine (Effexor) and Quetiapine (Seroquel)
• Sertraline (Zoloft) and Zyprexa (Olanzapine)
• Fluxoetine (Prozac) and Zyprexa (Olanzapine)

2. Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) is a medical procedure performed under anesthesia in which electrical currents are applied to a person’s head, causing a generalized seizure that affects the levels of neurotransmitters ⁸in the brain.

If medication-based treatments fail, the treating physician may refer the patient to electroconvulsive therapy (ECT). For people suffering from psychotic depression, electroconvulsive therapy is a safe and effective treatment option.

ECT is typically administered in a hospital, and sometimes, in dire cases, patients are taken to a hospital emergency room. While ECT ⁹is generally considered safe and effective for people who experience psychosis, suicidal ideation, and catatonia, it does carry a few risks, including:

• loss of short-term memory
• nausea, headache, and fatigue

In a systematic review and meta-analysis to test the efficacy and safety of ECT in depressive disorders, the findings revealed that ECT is an effective short-term treatment for depression and is found to be more efficient than drug therapy, the meta-analysis concluded.

3. Therapy

While therapy may not improve symptoms of psychosis on its own, it can be beneficial as a supportive treatment approach. For one thing, therapy provides a safe space to share distressing emotions and experiences. A therapist can also teach coping strategies for hallucinations and delusions.

Possible treatment approaches include:

• behavioral activation
• acceptance and commitment therapy
• cognitive behavioral therapy
• acceptance-based depression and psychosis therapy

Bottom Line

Treatment for psychotic depression should start in a residential mental health facility that offers rigorous inpatient treatments for people with significant psychological or behavioral health disorders, even though aftercare will include outpatient therapies.

A patient exhibiting symptoms of psychosis should be extensively assessed by a mental health expert (and potentially by a medical physician as well) before treatment can begin to ascertain whether their symptoms are severe enough to necessitate psychiatric hospitalization.

Medication and daily individual therapy sessions are the main components of long-term inpatient treatment for psychotic depression, with group and family sessions added as the patient’s recovery advances.

Studies have shown that the best treatment for persons with this disease is a mix of antidepressants and antipsychotics. At the same time, ECT (electroconvulsive or electroshock) therapy may occasionally be prescribed if the patient does not respond well to medicines.

The condition of psychotic depression is difficult to recover from. But for patients who begin treatment in an extended inpatient program, are genuinely committed to their healing process from initial treatment through aftercare, and have the complete and unconditional support of family and friends at each stage of their recovery, there is great hope for eventual recovery.

For more such related articles, click here.

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Last Updated on March 6, 2024 by Sathi Chakraborty, MSc Biology