Published On: August 17, 2022
Reviewed On: August 17, 2022
Updated On: July 5, 2023
While many people with depression have typical symptoms like feeling worthless, having difficulty thinking or focusing, feeling a sense of hopelessness, and having trouble sleeping, some may also experience psychosis. When people with depression experience symptomatic psychosis, they often lose touch with reality and have delusions or hallucinations.
Read on to learn more about depressive psychosis, including what it is and typical symptoms you may see, what causes it, how it’s diagnosed, and how to treat it.
When someone with unipolar depression, known as major depression, has accompanying psychosis, it’s called depression with psychosis or psychotic depression. Some research suggests that up to 50% of people with nonpsychotic depression might experience depression with psychosis at some point (note that this is the high-end range, and many of this group are in the geriatric population). A more typical range is that around 15 – 18% of people with depression will eventually express psychotic features.
While it’s more common to see psychotic features with other mental health conditions such as bipolar disorder or schizophrenia, or a combination of the two like schizoaffective disorder, major depression can cause psychosis as well. However, it isn’t fully understood why some people with depression experience psychosis and others don’t.
Depression with psychosis often begins with typical depressive symptoms, including:
When experiencing psychosis, the depression symptoms generally require immediate medical attention and in extreme cases, sometimes even hospitalization.
“Sometimes feeling tired, unable to concentrate, and sad can mean more than what we think. Observing your emotions and behaviors for a few days can help you identify the possible causes, giving you an opportunity to look for help and find solutions.”
The symptoms of depression psychosis can include:
An episode of psychosis requires immediate medical attention, as you may be at risk of self-harm or of causing harm to others.
Depression psychosis is not a standalone diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR). Still, it is listed as a subtype under major depressive disorder.
With depression psychosis, you’d have to meet the criteria for major depressive disorder first. You must experience five or more of the following symptoms in the same 2-week timeframe. In addition, 1 of the symptoms must include the first or second symptom.
In addition to meeting the criteria for major depressive disorder, you must also have symptoms of psychosis, such as hallucinations, delusions, or paranoia. If you’ve experienced a psychotic episode, it’s essential for your doctor to rule out other mental health conditions such as bipolar disorder or schizophrenia before getting a depression diagnosis.
Much like the causes of depression, there’s no one single known cause for depression and psychosis, but there are links to potential causes and risk factors.
“A particular combination of genes and high levels of the stress hormone cortisol are identified as the main causes of depressive psychosis. That’s why it’s so important to talk to a medical or mental health professional to get the help you need.”
When it comes to how to treat depression with psychosis, any episode of psychosis should be treated as a medical emergency. During a psychotic crisis, many people can greatly benefit from an in-patient stay in a mental health facility where they can be safe and doctors can stabilize the symptoms. Currently, there’s no FDA-approved form of medication used to treat depressive psychosis.
That said, depression medication is one way to treat psychotic depression. If someone with depression psychosis is already on an antidepressant, a doctor may add an antipsychotic medication to relieve any psychotic symptoms.
In cases of psychotic depression, combining an antidepressant with an antipsychotic can be much more effective than one or the other when used alone.
Some common combinations of antidepressants with antipsychotics are:
Electroconvulsive therapy, or ECT, is another psychotic depression treatment option. ECT uses electrical currents to produce a mild seizure in the brain. This seizure changes the levels of the chemicals in the brain that cause psychosis. Because of the intense nature of this treatment, ECT can only be administered by a psychiatrist or doctor in a hospital setting.
While there’s not as much research regarding the effectiveness of ECT therapy for depression, some studies show promise of high efficacy. For example, in one particular study, ECT showed a remission rate of 95%.
In addition, for the older population who may not tolerate the medication well, ECT might be the best form of treatment.
You’re not alone if you have depression and feel like you might have psychotic episodes, including hallucinations or delusions. The first step is getting a formal diagnosis from a licensed mental health care provider.
Once you have a diagnosis of depression and psychosis, you can work with a psychiatrist or therapist to determine the best course of treatment. Treatment can include a combination of medication, ECT, or both. In addition, psychotherapy will likely be an essential component of treatment.
When effective and proper treatment is implemented, the long-term prognosis for someone with psychotic depression is good. While many people do well with medication management alone, others may need a more intensive approach that includes electroconvulsive therapy. Both treatments can effectively manage some of the most severe symptoms of depression with psychosis.
Although treatments are often successful, some medications can also have side effects, including:
For some people, though, the possible side effects can be minor compared to the potential for self-harm or harming others during psychotic, severe episodes.
If you or your loved one shows signs of depression and psychosis, don’t hesitate to contact a healthcare provider as soon as possible. Recovery is an achievable goal with the proper treatment.
If you’re looking for mental and behavioral health help but aren’t sure where to start, consider Talkspace. Our online therapy platform makes therapy simple, affordable, and convenient. You can get the help you need in managing depressive psychosis so you can learn to manage your condition. You don’t have to go on struggling — help is out there, and Talkspace can ensure you get it.
Brain & Behavior Research Foundation. Published 2011. Accessed July 10, 2022.
Rothschild A. Schizophr Bull. 2013;39(4):787-796. doi:10.1093/schbul/sbt046. Accessed July 10, 2022.
Gaudiano B, Zimmerman M. Acta Psychiatr Scand. 2009;121(6):462-470. doi:10.1111/j.1600-0447.2009.01477.x. Accessed July 10, 2022.
Qin D, Rizak J, Feng X et al. Sci Rep. 2016;6(1). doi:10.1038/srep30187. Accessed July 10, 2022.
Flint A, Meyers B, Rothschild A et al. BMC Psychiatry. 2013;13(1). doi:10.1186/1471-244x-13-38. Accessed July 10, 2022.
Petrides, M.D G, Fink, M.D. M, Husain, M.D M. J ECT. 2022;17(4):244-253. Accessed July 10, 2022.
Cynthia Catchings is a trilingual licensed clinical social worker-supervisor, mental health consultant, professor, and trainer for federal law enforcement agencies. Cynthia has over 15 years of experience in the mental health profession. She is passionate about women’s mental health, life transitions, and stress management. Her clinical work, advocacy, and volunteer service have focused on working with domestic violence survivors and conducting mental health research in over 30 countries.