Depression with psychotic features (psychotic depression): symptoms and treatment

Psychotic depression is not a separate illness from depression but a severe form in which psychosis is also present. Rethink Mental Illness describes it as moderate or severe symptoms of depression together with symptoms of psychosis, and says it is also known as depression with psychotic symptoms.

Psychosis means losing some contact with reality. In psychotic depression this takes the form of delusions, beliefs that are unlikely to be true, and hallucinations, such as hearing voices. Rethink points out the difference from schizophrenia: in schizophrenia, depressive symptoms such as low mood, fatigue and suicidal thoughts are usually absent.

Rethink says it is hard to find accurate figures, but a study it cites suggests about 1 in 250 people are affected, which it describes as less common than schizophrenia. New mothers can also experience it after the birth of a baby.

The NHS describes the depressive part as feeling sad and hopeless for most of the day, practically every day, with no interest in anything, so that getting through the day feels almost impossible. Other typical symptoms include the following.

• Fatigue (exhaustion), disturbed sleep and changes in appetite.

• Feeling worthless and guilty.

• Being unable to concentrate or being indecisive.

• Thoughts of death or suicide.

• Delusions and hallucinations that fit a depressed mood, such as being convinced of guilt or blame.

• Psychomotor agitation, which means not being able to relax or sit still, or at the other extreme psychomotor retardation, where thoughts and physical movements slow down.

The NHS says the cause is not fully understood, that depression has no single cause, and that it is not known why some people with severe depression also develop psychosis. Genes probably play a part, as severe depression can run in families, and life events such as bereavement, relationship problems, financial problems, health problems or traumatic experiences can be the cause for some people.

NHS inform adds that many people who have psychotic depression have experienced a difficult time in childhood. Rethink lists isolation, past abuse or neglect, a family history of mental illness, stressful events, and having other mental health problems among the risk factors.

The NHS notes that people with psychosis are often unaware that they are thinking and acting strangely, so it is often down to friends, relatives or carers to seek help. If the person has a previous diagnosis, you could contact their social worker or mental health team. If it is the first time they have shown symptoms of psychosis, contact their GP.

If you believe symptoms are placing the person or others at risk of harm, the NHS says you can take them to A&E if they agree, call a GP or use an NHS urgent and emergency care service, or call 999 for an ambulance. Rethink advises contacting NHS 111 for urgent mental health support.

Rethink also points out that NHS early intervention in psychosis teams should support people experiencing psychosis for the first time, and that NICE says treatment should start within 2 weeks of referral. You can usually self-refer, and friends or family can often refer you too.

Rethink says a psychiatrist might diagnose depression with psychotic symptoms after a mental health assessment, and that it can take more than one assessment. The psychiatrist must think that you have symptoms of moderate or severe depression and symptoms of psychosis over a period of time, using diagnostic manuals such as ICD-11 and DSM-5.

A GP is usually the first point of contact. A GP can check for physical causes and arrange referral to a mental health team where needed. Symptoms that arise suddenly with confusion or drowsiness also need to be assessed for physical illness.

The NHS says treatment for psychotic depression involves medicine, talking therapies and social support. NHS inform adds that some people need intensive home treatment with several visits a day, or a stay in hospital. Treatment is usually effective, but follow-up appointments are needed so that progress can be monitored.

Rethink describes peer support groups, recovery colleges and wellness action plans as ways to manage symptoms and notice early signs of becoming unwell. These are often available through the local mental health team.

The NHS says that if you have been diagnosed with psychotic depression it is your legal obligation to tell the DVLA, and that you must not drive until you have been assessed as safe to do so.

Family and friends are often the first to notice. The NHS suggests charities such as SANE and Mind for further information and support for people living with psychosis and those around them.

On the NHS the route is through the GP or an early intervention in psychosis team to community mental health services, with crisis and home treatment teams or inpatient care if needed. Treatments such as ECT are hospital-based and are only recommended by specialists, as the NHS describes, if other treatments have not worked.

Some people choose a private psychiatrist for faster assessment or continuity. Because the illness can become severe quickly, any private care should be coordinated with the GP so that risk assessment and monitoring are not lost.