Psychotic Major Depression

Major depressive symptoms can occasionally accompany psychotic symptoms, characterized by a loss of reality and delusions (false beliefs) or hallucinations (false sensory perceptions). The diagnosis in these situations is a severe major depressive episode with psychotic features.

What is Psychotic Major Depression?

Psychotic major depression is also called depression with psychotic features. The psychotic symptoms may be consistent or inconsistent, depending on the patient's mood. Hallucinations with messages such as "you are a worthless human being who deserves to suffer for your faults," for instance, would be seen as having "mood−congruent psychotic traits." Patients with depression who have psychotic symptoms are more likely to need hospitalization and treatment with a combination of antidepressant and antipsychotic drugs.

Typically, any hallucinations or delusions are mood congruent, meaning that they seem in some way relevant to severe depression since the content is negative in tone and centers on ideas like personal inadequacy, blame, deserved retribution, death, or illness. For example, some people suffering from severe depression believe that their internal organs have failed.


It includes −

  • There are delusions or hallucinations at any point during the episode.

  • If psychotic features are there, indicate whether they are mood−congruent or mood−incongruent −

  • With mood−congruent psychotic features − All delusions and hallucinations that occur during manic episodes include content that is consistent with the standard themes of grandiosity, invulnerability, etc., but they may also have themes of suspicion or paranoia, particularly about other people's doubts about the person's abilities, accomplishments, etc.

  • With mood−incongruent psychotic features − The information in delusions and hallucinations conflicts with the episode polarity themes listed above, or the content contains both mood−incongruent and mood−congruent themes.

  • Psychotic depression can cause people to lose sight of their goals and trigger suicidal thoughts.

  • People with PMD may have symptoms such as low energy, headaches, digestive problems, nervousness, and chronic discomfort.

Mood-Congruent Psychotic FeaturesMood-Incongruent Psychotic Features
This includes personal inadequacy, guilt, disease, death, deserved punishment.
These include delusion of control, persecution, thought broadcasting, and though insertion.
The actions of the person match the current mood of the person.
The actions of the person do not match the current mood of the person.

Similarities and Differences Between Psychotic and Non−Psychotic Patients

Psychosis is characterized by false fixed beliefs and guilt, destitution, or disease symptoms. Importantly, psychotic depression is relatively similar to other forms of depression in that it can affect a person's mood, behavior, and some basic functions, including sleep. It can impact a person's body by causing headaches, intestinal issues, chronic discomfort, and issues with concentration, memory, and decision−making. In addition, depression can cause insomnia, leading to fatigue when a person has difficulty pronouncing words or shows signs of exhaustion.

Compared to people with depression without psychotic features, those who are psychotically depressed are more likely to experience longer episodes, greater cognitive impairment, and a worse long−term prognosis. Any repeated episodes are also likely to be accompanied by psychotic symptoms.

Differences Between PMD and Schizophrenia

PMD delusions may be less overt than those experienced in schizophrenia. Many people experience ruminations that might not quite qualify as delusions. These "near delusions" do, however, frequently signal a weak response to antidepressant monotherapy. Compared to schizophrenia, hallucinations have been said to occur less frequently in PMD. However, they may still be rather common.


It includes −

Antidepressant Monotherapy − Given the distinct phenomenology of psychotic depression, it is understandable why the MDD standard treatment may not be as consistently effective in PMD. Antidepressant monotherapy, for instance, is less effective in PMD. Tricyclic antidepressants have been used in numerous research on treating psychotic depression (TCAs). Even though TCA monotherapy is a well−researched treatment for MDD, studies on amitriptyline, imipramine, and other TCAs in treating PMD have yielded mediocre results. A few monotherapy studies have shown that SSRIs are effective for treating PMD.

Combination Treatment − In numerous studies that revealed TCA monotherapy to be successful in treating PMD, it was discovered that the addition of conventional antipsychotics considerably increased efficacy. Although antidepressant−antipsychotic combination medication is currently the most widely accepted and used "standard of care" for psychotic depression, few prospective, double−blind, controlled trials have examined its effectiveness. Treatment research has also shown that patients respond well to minor placebo effects.

ECT − One of the best therapies for PMD has been said to be electroconvulsive therapy (ECT).


PMD is still a condition that is not fully understood. Different treatment approaches may be necessary to effectively treat PMD, given the higher prevalence of delusions, hallucinations, and more severe cognitive symptoms. The current gold standard of treatment for PMD is either ECT or a combination of an antidepressant and an antipsychotic. This guideline is based on a small amount of data, in any case. Furthermore, there are not many randomized controlled studies examining the effectiveness of combined therapy and ECT in PMD. The treatment data trends indicate that TCAs alone are insufficient to treat PMD. It is plausible that some of the more severe cognitive abnormalities in PMD may be made worse by the anti−muscarinic actions of TCAs like amitriptyline. Given the significant side−effect burden that antipsychotics may cause, further research is required to determine whether combination therapy, particularly newer atypical antipsychotics, is the best form of pharmacotherapy.

Moreover, the HAM−D is not certain to be the best scale for assessing progress in PMD patients. The HAM−D does not adequately capture the unique traits of PMD. Similar to this, most scales used to assess psychosis in PMD, like the Brief Psychiatric Rating Scale, were created to assess schizophrenia symptoms. PMD's psychotic symptoms do not always resemble those of schizophrenia. Most patients cannot determine the best effective treatment for PMD with certainty until better measures are developed, and randomized comparison trials with newer agents are finished.