Major depression on its own is debilitating and scary. But in some individuals, it occurs along with psychosis, a transient mental state characterized by abnormal perceptions that may include delusions and hallucinations. When psychosis accompanies major depression, it’s called psychotic depression or depression with psychosis. It’s estimated that anywhere from 14 to nearly 50% of people diagnosed with depression have psychotic depression, and geriatric patients are especially prone to it.1

Psychotic depression is taken very seriously by mental health professionals because the individual suffering from it is at an increased risk of self-harm.

“The suicide rate in people with psychotic depression, when they are ill and in their acute phase, is much higher than it is with major depression,” says Anthony J. Rothschild, MD, the Irving S. and Betty Brudnick Endowed Chair, Professor of Psychiatry at the University of Massachusetts Medical School in Worcester, Massachusetts and the author of the Clinical Manual for the Diagnosis and Treatment of Psychotic Depression.

It’s important to distinguish psychotic depression from psychosis as well as schizophrenia, experts say.  Psychosis by itself is not a disease, explains Timothy B. Sullivan, MD, chair of Psychiatry and Behavioral Sciences at Staten Island University Hospital in Staten Island, New York.  “It’s not an illness in itself, just as fever is not an illness,” he explains. “Psychosis is caused by an impairment in the part of the brain that helps us discern what is happening internally versus what is happening externally.”

Psychosis is common, says Theresa Nguyen, LSCW, of Mental Health America (MHA).  “Some 3% of the population experiences it at some point,” she says. “Some brain changes makes a person see or hear things that are not there. And the longer the person experiences psychosis without getting treatment, the more she starts to become more convinced that the things she sees, hears, and believes are real.”

“While psychosis can look like schizophrenia, an individual with schizophrenia will have delusions and hallucinations regardless of whether they are depressed,” says Ms. Nguyen.


To be called a psychotic depression, according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, major depression must be present along with delusions and/or hallucinations. If psychotic features are present, they must be either mood-congruent (having to do with typical depressive themes like personal inadequacy, death, or deserved punishment) or non mood-congruent (in other words, not involving the depressive themes). Typically, the psychotic symptoms have a depressive “theme,” such as delusions of guilt, poverty, or illness.2

Typically, the person with psychotic depression exhibits a low, sad mood, with poor concentration and feelings of lack of self-worth and guilt, says Anil Malhotra, MD, vice chair of research in the department of psychiatry at the Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. “And there are the psychotic features,” he says. “The person hears or sees voices and things that are not real, which are hallucinations, and believes things that are not real, which are delusions.”

What’s important to keep in mind is that hallucinations are much less common than delusions in a person with psychotic depression, says Dr. Rothschild. “The delusions are very common and are of a depressing, nihilistic nature,” he explains. “For instance, the person may say they are dying of cancer, or that they lost all their money, or that they did something bad, like not pay their taxes. The interesting thing is that on the surface, these delusions could be true. They have an air of reality about them.”

One of the reasons that psychotic depression is not easily diagnosed, he says, is that people with psychotic depression often realize that their thoughts may not be “quite right” so they keep them to themselves. Dr. Rothschild described one patient who was convinced that he was going to die of prostate cancer. Multiple doctors had examined him and found his prostate to be healthy, but he refused to accept this news. Finally, it was suggested that he have a consultation with Dr. Rothschild, who diagnosed him with psychotic depression. After treatment, the patient got better.

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Risk Factors

One of the biggest risk factors is childhood trauma, says Dr. Rothschild. “Early life trauma puts you at risk,” he says. “The loss of a parent before age 11, for instance, or any trauma such as sexual or physical abuse puts you at risk. And if a person with these risk factors gets depressed as an adult, they are at a higher risk for psychotic depression.”

Additionally, it’s more likely for people to develop psychotic depression as they get older. “Psychotic depression can occur in any age group but it is not uncommon for someone with no prior psychiatric history to present with psychotic depression in their 60s, 70s, or 80s,” Dr. Rothschild says. “In older people, delusions of poverty or somatic delusions, for example, believing one is suffering from a fatal illness, are more likely to be present.”

How Psychotic Depression Differs from Schizophrenia

“If the person has pure psychosis, without much depression, it is more likely to be schizophrenia,” says Amit Anand, MD, professor and Vice Chair for Research at the Center for Behavioral Health at the Cleveland Clinic. “And with schizophrenia, the depression is usually not predominant and the person has hallucinations and delusions that don’t go away. They also have decreased thinking, feelings and motivation.”

Schizophrenia tends to make an appearance for the first time when the patient is in their late teens or early 20s while individuals can have psychotic depression at any age, Dr. Rothschild says. “Schizophrenia is more long-lasting and is not episodic,” he explains. “The delusions tend to be more bizarre, although we don’t make the diagnosis based on the type of delusion.”

Treatment for Psychotic Depression

There are two modalities of treatment for psychotic depression, Dr. Rothschild says. “The combination of an antidepressant with an antipsychotic is one, and electroconvulsive therapy (ECT) is the other,” he says. “That is a decision to make with the family and it depends on the situation.”

In some older patients, ECT may be used in order to avoid the side effects of medication. Sometimes a course of ECT is prescribed and then the antidepressant and antipsychotic are taken afterward. Talk therapy can be helpful, too, he says, but only after the first line treatment of medication or ECT has been started, Dr. Rothschild says.

The prognosis for recovering from psychotic depression is excellent, Dr. Rothschild says. “As you can imagine, if you have an episode of psychotic depression it can cause a lot of disruption in your life,” he says. “It depends on the person but generally speaking, a person who receives treatment for psychotic depression can be back to their normal self in a couple of months.”

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Last Updated: Apr 10, 2019