Psychotic Depression: Losing Touch With Reality

This severe type of depression can cause someone to see or hear things that are not really there. Could you be at risk?

Medically Reviewed

You may be familiar with some of the symptoms of clinical depression — profoundly depressed mood, fatigue, and feelings of hopelessness. But did you know that depression may also be linked to psychosis?

The National Institute of Mental Health (NIMH) defines someone who is “psychotic” as out of touch with reality, likely experiencing false beliefs, known as delusions, or false sights or sounds, known as hallucinations. So when do depression and psychosis go hand in hand?

Psychotic Depression: What Is It?

"Psychotic depression is a relatively rare condition that occurs when someone displays both severe depression and a break with reality. The loss of contact with reality may take the form of delusions, hallucinations, or thought disorders," explains James C. Overholser, PhD, professor of psychology and director of clinical training at Case Western Reserve University in Cleveland.

Approximately 25 percent of people who have depression that is severe enough to cause them to be admitted to a hospital also have psychosis or psychotic depression. "Major depression with psychosis" is another term used to describe the condition of psychotic depression.

Psychotic Depression: Symptoms

The delusions or hallucinations of people who have psychotic depression often involve beliefs, voices, or visions telling them that they are worthless or evil. In some cases, people may hear voices telling them to harm themselves. In addition to these symptoms, psychotic depression may also cause the following:

  • Feeling persistently worried and on edge
  • Falsely believing you have other illnesses or diseases
  • Difficulty sleeping
  • Poor concentration

Psychotic Depression: Getting a Diagnosis

If you or a loved one has symptoms of psychotic depression, see your doctor right away. Your doctor will perform a medical examination and blood work to make sure your symptoms are not caused by a medical disease or a reaction to medications. A complete psychiatric evaluation will also be done to distinguish psychotic depression from other types of depression and from other psychotic disorders such as schizophrenia.

The cause of psychotic depression is not known, but having a family history of depression or psychosis increases the risk. One of the differences between psychotic depression and schizophrenia is that people with schizophrenia believe their hallucinations or delusions are real. In most cases, people with psychotic depression know their symptoms are not real. They may actually be afraid or ashamed to tell their doctor about these symptoms, which can make the disorder that much more difficult to diagnose.

Psychotic Depression: Getting Treatment

Antidepressants and antipsychotic drugs are often used to treat psychotic depression. "It is likely that psychotic depression has more of a biological basis [than other types of psychosis], and seems to respond more to biological interventions. Treatment usually requires a combination of medications," notes Overholser. Electroconvulsive therapy, or shock therapy, may also be effective in some cases.

A recent review of 10 studies involving over 500 patients treated for psychotic depression concluded that it may be best to start with an antidepressant drug alone and then add an antipsychotic drug if needed. Using an antipsychotic drug alone is not appropriate therapy. Treatment of psychotic depression is more likely to require hospitalization than other types of depression, and long-term medications may be necessary.

If you have symptoms of depression combined with hallucinations or delusions, don't hesitate to ask for help. It is particularly important to share the details of your symptoms with your doctor, because psychotic depression must be managed differently than other types of depression. The most serious risk of psychotic depression is suicide, so getting appropriate treatment as soon as possible is crucial.

Psychotic depression is an illness, not something to be ashamed of or a weakness. It is also a treatable condition, and most people recover within a year.