An Overview of Psychotic Depression

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Some people with severe depression also experience psychosis in addition to the usual symptoms of depression, such as depressed mood, appetite changes, and loss of interest in activities previously enjoyed. Psychosis is a condition in which a person begins to see and/or hear things that aren't really there (hallucinations) or experience false ideas about reality (delusions). There may also be disorganized or disordered thinking. When psychosis occurs alongside depression, it is called psychotic depression.

Prevalence and Risk Factors

It is estimated that about 3% to 11% of all people will experience severe depression during their lifetime. Of those who experience severe clinical depression, about 14.7% to 18.5% will develop depression with psychotic features. This type of depression also appears to become more common as people age.

It is, however, impossible to predict who exactly might be prone to psychotic depression, as not enough is known about the condition's causes.

The definitions and measurement tools for depression evolve and change, meaning that these statistics are always shifting. From what we know now, some of the factors that may make you more prone to depression, in general, include:

  • Being a woman: Women are twice as likely as men to develop depression; about two-thirds of those who develop severe depression are women.
  • Having a difficult childhood: People who experienced adversity as children are more predisposed to depression.
  • Having a parent or sibling with depression: A propensity toward depression, especially severe depression, tends to run in families. If you have a parent or sibling who has had depression, you are more likely to develop it yourself.


A person with psychotic depression will experience a combination of depression symptoms, potentially including:

  • Depressed mood
  • Diminished interest or pleasure in activities previously enjoyed
  • Fatigue or lack of energy
  • Feelings of worthlessness or guilt
  • Inability to concentrate
  • Significant changes in weight and appetite
  • Sleep difficulties
  • Thoughts of death or suicide

In addition to the above symptoms, people with psychotic depression will also experience delusions and/or hallucinations.

People with other mental illnesses, such as schizophrenia, may also experience psychosis. In the cases of psychotic depression, the hallucinations and delusions that people experience are depressive and tend to focus on themes of hopelessness and failure.

Psychosis associated with schizophrenia features impossible or bizarre themes that are disjointed and not connected to mood or affective states. 


One theory is that a particular combination of genes must be inherited in order for a person to develop psychotic depression. Certain genes might be responsible for depression symptoms while others might be responsible for psychotic symptoms, making it possible for an individual to inherit a genetic vulnerability to depression, psychosis, or both.

The theory that a combination of genes impact depression and its symptoms would explain why not all people with depression develop psychosis.

Another theory is that high levels of the stress hormone cortisol could be involved. High levels of cortisol are often found in people with depression.


At present, psychotic depression is not considered an illness separate from depression. Instead, it is considered to be a sub-type of major depressive disorder (MDD).

In order to be diagnosed with psychotic depression, officially known as major depressive disorder with psychotic features, a person must first meet the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for major depressive disorder. In addition, the person must exhibit signs of psychosis, such as hallucinations and delusions.

The diagnosis of psychotic depression usually involves a medical history. Your doctor will ask questions about your symptoms and family history. An evaluation by a physician might also include testing to rule out other potential causes of the patient's psychotic symptoms, such as drugs, another medical condition, schizophrenia, or bipolar disorder.

Classification of Psychotic Depression

While the DSM-5 lists psychotic depression as a subtype of major depression, it does not indicate that this type of depression is any more severe than other subtypes. The International Classification of Diseases (ICD-11), on the other hand, classifies psychotic depression as the most severe form of major depressive disorder. 

In order to be diagnosed with major depressive disorder with psychotic features, you must experience at least five depressive symptoms for a minimum of two weeks. Such symptoms include low mood, loss of pleasure or interest, irritability, appetite changes, and changes in sleep. 

A diagnosis of psychotic depression also includes experiencing symptoms of psychosis, such as paranoia, hallucinations, and delusions, in addition to the depressive symptoms.


There is currently no federally approved treatment for psychotic depression. However, the American Psychiatric Association (APA) recommends either the combination of an antidepressant and antipsychotic or electroconvulsive therapy (ECT) as the first-line treatment for psychotic depression.


Common antidepressant medication choices include serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). Evidence suggests that combination therapy with an antidepressant like an SSRI or SNRI plus an antipsychotic is more effective than either of the two medications alone.

However, there are potential risks associated with using both medications together. A 2020 study published in the journal PLOS ONE found that adding an atypical antipsychotic (specifically quetiapine, risperidone, aripiprazole, or olanzapine) to an antidepressant is associated with an increased risk of death.

That being said, more research is needed to better understand this potential risk. Furthermore, every situation is different. For some, the benefit of augmenting with an antipsychotic may be well worth the potential risk. The best thing to do is to consult with your doctor and try to exhaust other less potentially risky options.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a safe and highly effective treatment for people with psychotic depression who do not respond to traditional medications. Because ECT provides such rapid relief, it is also recommended for those struggling with suicidal thoughts.

ECT may be the most rapid treatment, but ongoing treatment, which often includes antidepressants, is needed to prevent a recurrence of symptoms.


Psychosis can make functioning difficult since people experience distortions in reality. Because psychotic symptoms can increase the risk of accidental or intentional self-harm, it is important to receive appropriate treatment from a qualified health professional.

Prognosis can depend on how soon someone receives treatment for psychotic depression. The longer it takes for treatment, the more likely it is that an individual may need emergency medical services. 


One study found that 86% of people with first-episode psychotic depression achieve syndromal recovery, but only 35% recovered functionally. A large number of individuals (41%) had their diagnosis changed to bipolar disorder or schizoaffective disorder. 

Researchers suggest that psychotic depression is understudied, underdiagnosed, and undertreated. Combination medication treatments and ECT have been shown to be effective, but further research is needed to establish how long antipsychotic medications need to be taken.

The best way to cope is to talk to your doctor if you have symptoms of depression or suspect that you may be experiencing symptoms of psychosis. Once you have been treated and your condition has stabilized, be sure to stick to your doctor's advice and continue taking your medication in order to prevent future relapse.

A Word From Verywell

Psychotic depression can be frightening, but effective treatments are available. Fortunately, the prognosis for recovery is good with appropriate treatment. With treatment, you can find relief from symptoms of depression and psychosis and feel more like your regular self.

If you are experiencing thoughts of suicide or are considering harming yourself, call 911 immediately or contact the National Suicide Prevention Lifeline at 988.

For more mental health resources, see our National Helpline Database.

11 Sources
Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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Additional Reading

By Nancy Schimelpfening
Nancy Schimelpfening, MS is the administrator for the non-profit depression support group Depression Sanctuary. Nancy has a lifetime of experience with depression, experiencing firsthand how devastating this illness can be.