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Key points
- Around 10% of individuals with major depression may experience psychotic features.
- Major depressive disorder with psychotic features is associated with a high risk of suicide.
- Early identification and treatment of major depression with psychotic features is imperative.
Psychosis is a rainbow of experiences involving changes in how we perceive the world. The most common alterations within psychosis are unshared sensory phenomena, like voices and visions, and unusual thoughts, like paranoia. Disorganized thinking is also common.
The diagnosis most commonly associated with psychosis is schizophrenia. Yet, the majority of people who experience psychosis do not have schizophrenia.
One often overlooked source of psychosis is severe depression with psychotic features. In this serious presentation of depression, perceptions and cognitions are distorted by ultra-low moods with mood-congruent delusions and hallucinations. One person might feel that their life is in ruins or that police are tracking them. Another might hear voices shouting critical remarks.
In a study of 573 people experiencing a first episode of major depression, close to 10% of participants reported psychotic symptoms such as hearing voices or paranoia (Shen et al., 2020). Unsurprisingly, these individuals had higher scores on measures of depression and anxiety. The trial also identified psychosis as a risk factor for suicidal thinking among participants in the sample.
Psychosis in depression can create an image of terror regarding one's life circumstances and future, placing someone in a precarious mental state. Due to the risk involved, identification and treatment of psychosis in depression is imperative. Tragically, death by suicide in psychotic depression is even higher than in severe depression without psychosis, making it one of the most lethal mental health conditions and arguably the most severe form of depression (Paljärvi et al., 2023).
Nonetheless, in clinical samples outside research, diagnosis of major depression with psychotic features is rare. Researchers estimate it often goes unrecognized (Wu et al., 2024).
Many clinicians are not familiar with the diagnosis or hold a stereotype of what psychosis looks like that is not always accurate. Someone living with major depression with psychotic features is likely to have a different presentation than those with other conditions associated with psychosis, like schizophrenia.
Delusions in this condition tend to be more realistic than in other manifestations of psychosis. For example, a person might believe that an ex is trying to harm them as opposed to a more bizarre belief like that the FBI is out to get them. What qualifies the belief as a delusion is the intensity, the fixation, and the difficulty of releasing the belief when presented with contradictory evidence. In addition, the experience of voices might be more internal voices than external ones.
Unlike psychosis in schizophrenia, individuals with psychosis as part of depression also often maintain some insight into the aberrant nature of their experiences. Individuals also may not readily report their psychotic symptoms to providers due to shame and fear.
Seeking Support
Medication, including antidepressant and antipsychotic drugs, is sometimes utilized to treat major depression with psychotic features. More recently, research has suggested that ketamine may be a promising intervention for major depression with psychotic features as well (Gałuszko-Węgielnik et al., 2023).
Psychotherapy also often plays a role in recovery from major depression with psychotic features. Acceptance commitment therapy (ACT), in particular, has demonstrated success in reducing the symptoms and impairments involved in this type of depression (Gaudiano et al., 2007). ACT focuses on accepting emotions and defusing away from tricky thoughts. Connecting with values and taking steps toward those values, mindfulness, and developing a complex understanding of the self are also parts of the therapy.
If you notice signs of psychosis in yourself or someone you love, know that help is available. With support, many come through severe depression with psychotic features. Reaching out to a medical professional for a complete evaluation is a first step. With treatment, depression and psychosis can improve. There is hope.
To find a therapist, please visit the Psychology Today Therapy Directory.
References
Gałuszko-Węgielnik, M., Chmielewska, Z., Jakuszkowiak-Wojten, K., Wiglusz, M. S., & Cubała, W. J. (2023). Ketamine as add-on treatment in psychotic treatment-resistant depression. Brain Sciences, 13(1), 142.
Gaudiano, B. A., Miller, I. W., & Herbert, J. D. (2007). The treatment of psychotic major depression: is there a role for adjunctive psychotherapy?. Psychotherapy and psychosomatics, 76(5), 271-277.
Paljärvi, T., Tiihonen, J., Lähteenvuo, M., Tanskanen, A., Fazel, S., & Taipale, H. (2023). Psychotic depression and deaths due to suicide. Journal of affective disorders, 321, 28-32.
Shen, Y., Wei, Y., Yang, X. N., Zhang, G., Du, X., Jia, Q., & Zhang, X. Y. (2020). Psychotic symptoms in first‐episode and drug naïve patients with major depressive disorder: prevalence and related clinical factors. Depression and anxiety, 37(8), 793-800.
Wu, Y., Zhao, X., Li, Z., Yang, R., Peng, R., Zhou, Y., & Zhang, X. (2024). Prevalence and risk factors for psychotic symptoms in young, first-episode and drug-naïve patients with major depressive disorder. BMC psychiatry, 24(1), 66.
