Psychotic depression

Mental health care


  1. What is psychotic depression?
  2. Who gets psychotic depression?
  3. Diagnosis
  4. What causes psychotic depression?
  5. How is psychotic depression treated?

What is psychotic depression?

When some people have a major depressive disorder or severe clinical depression as it is most commonly called, they can experience delusions and hallucinations. These people are described as having psychotic depression.

Those with severe clinical depression can be in a depressed and low mood for the majority of the day, almost every day and can lose interest in nearly everything.

Mental health workers refer to this depression as ‘unipolar’ depression as opposed to ‘bipolar disorder’, which is when people have episodes of mania as well as episodes of depression.

There are other symptoms that come with severe clinical depression including disturbed sleep patterns, extreme tiredness and appetite changes. Many people will feel guilty and worthless and will not be able to concentrate or make decisions. Some people are also extremely anxious, worried or have exaggerated concerns about their own health. Daily life is very difficult for people who have severe clinical depression.

The hallucinations and delusions that most people with psychotic depression experience usually reflect them having a very low mood. The hallucinations and delusions are extremely negative, self-blaming, self-punishing and self-critical, which makes people have increased anxiety.

‘Psychomotor agitation’ – the inability to sit still or relax – is often an experience that those with psychotic depression have. They may move their limbs a lot, fidget or rock, for example.

Being severely or acutely anxious, often because of psychosis symptoms, will contribute to having psychomotor disturbance.

Unipolar depression is also often episodic and research has shown that most people who have one severe clinical depression episode will have at least another episode in the future. When people have had 2 or 3 episodes, there is a substantial increase in relapse risk.

Who gets psychotic depression?

There are estimated numbers on the number of people who will experience severe clinical depression at one moment or another in their lives. Estimates range between three people in every hundred to eleven. Men are half as likely as women to get depression, which means that two-thirds of those with severe clinical depression are women.

It must be said, however, that not all people with severe clinical depression experience psychosis symptoms. Around 10 to 15% of those with a diagnosis of severe unipolar depression go on to have symptoms of psychosis at some stage.

It is not known why some people develop delusions and hallucinations while others don’t. Therefore, doctors can’t predict which patients with the condition will have these symptoms.


The systems for classifying mental health conditions that mental health professionals use describe psychotic depression as being a major depressive disorder sub-type. Doctors will use the ‘major depressive disorder’ criteria or ‘severe depressive episode’ accompanied by delusions and hallucinations.

Mental health specialists make diagnoses by asking people to describe their symptoms in detail. They also ask about a person’s previous history of depression and whether or not any family members have had depression or an episode of psychotic depression.

It is often difficult to make a diagnosis. Psychosis symptoms can be subtle and those who have depression are often embarrassed if they have delusions and hallucinations and so don’t report experiencing them. This means that there is a danger of being misdiagnosed. If people have psychomotor agitation, for example, it could be that they are diagnosed as having anxiety.

It is vital that mental health specialists establish if people have psychosis symptoms and unipolar depression or if they have bipolar disorder. This is important because bipolar disorder and psychotic depression are treated differently.

What causes psychotic depression?

It isn’t known why some people with unipolar depression also have psychosis symptoms but it is thought that genes are involved.

Studies show that unipolar depression and in particular severe depression runs in families. You have a much higher chance of getting depression if your first-degree relative (sibling, mother or father) has had unipolar depression. It is also more likely for those who have had trauma or adversity in their childhood.

Genes that make depression more likely have been identified and there are also genes that play a part in psychosis symptoms. Some research suggests that people who inherit a gene combination are more likely to get psychotic depression. It is not yet understood, however, how many different genes play a part or how the genes interplay. There is a theory that we have a set of genes responsible for contributing to developing psychosis and there might be some specific genes that are responsible for determining whether or not people then go on to develop unipolar depression, schizophrenia or bipolar disorder.

Specialists also believe that elevated levels of cortisol, the stress hormone, could be involved too. Higher levels of cortisol are often found in people with mental health problems like depression.

Some specialists believe that the topic of hallucinations and the voices people hear when they have psychotic depression could be linked to traumatic events in the person’s distant or recent past.

How is psychotic depression treated?

People will be referred to specialist mental health professionals if they have delusions and hallucinations alongside severe clinical depression. It is also a requirement for some of these people to spend time in hospital. There are not a lot of specialist units in the UK so these people often go on a general psychiatric ward. Others who don’t need hospitalization can be treated under the care of a home-treatment and community-based team.

Initially, treatment focuses on the depression and not the psychosis symptoms. Normally, people will already have medication for their severe depression e.g. antidepressants or a drug combination that might include mood stabilisers, antidepressants and anxiolytics (drugs for anxiety). NICE (the National Institute for Health and Care Excellence) gives the recommendation to doctors that people should have access to psychological therapies alongside their medication for severe clinical depression.

When hallucinations and delusions develop, specialist mental health workers might also prescribe antipsychotic medication. There hasn’t been a lot of research into good drug combinations for psychotic depression, however.

The guidance from NICE on the management and treatment of adult depression states that mental health workers need to consider giving antipsychotics although it does acknowledge the lack of available evidence in terms of type and dose.

Psychotic depression sufferers may also benefit from electroconvulsive therapy (ECT). NICE says that ECT can and should be used when treating profound depression but not the psychosis symptoms. It also states that ECT should only be given when there is an urgent need for treatment or if other treatments have not worked for the depression. ECT always happens in hospital under general anaesthetic and involves an electric current being passed through the brain. Doctors need to explain to their patient how this treatment works and its potential side effects e.g. memory loss. Patients will have to consent for ECT.

Other treatments on offer for severe clinical depression are in the development and testing process. This includes repetitive transcranial magnetic stimulation (rTMS). This process involves an electromagnet being put on the scalp in order to produce magnetic pulses to stimulate a part of the brain and reduce its activity. Throughout this process, the patient remains conscious and does not need any anaesthetic. rTMS is not recommended by NICE as a depression treatment because sufficient evidence of its efficacy does not yet exist.

Other studies are currently trialling drugs that might reduce levels of cortisol and some research is looking at how effective ‘vagus nerve stimulation’ is. This when there is an electrode put into the brain to regulate and stimulate electrical activity constantly.