Hallucinations are sensory
perceptions that seem totally real to you but that occur without any external cause or source. They can seem so real that
you might not even realize that they're not. They can be:
- auditory (sounds, usually voices,
the most common type of hallucination);
- visual (sights, usually images and/or flashes of light);
- gustatory (tastes, usually foul and/or unpleasant);
- olfactory (odors, usually foul
- tactile (touches, usually being touched, electric shocks, and/or something
creeping/crawling on and/or under your skin);
- and/or proprioceptive (inside your body, usually
an electric current and/or shock).
There's no single cause for Depression. Rather, it most likely
results from a combination of genetic, biochemical, environmental, and psychological factors. Depression is a disorder of
the brain. Brain-imaging scans such as magnetic resonance imaging (MRI) have shown that the parts of the brain responsible
for regulating mood, thought, sleep, appetite, and behavior function abnormally in depressed people. In addition, important
neurotransmitters (chemical messengers) are out of balance. This knowledge doesn't explain WHY people become depressed, however.
Some depressions appear to run in families, suggesting a genetic
component. Depression also occurs in people without family histories of depression, however. Research indicates that the probability
that any individual will experience Depression results from the interaction between multiple genes and environmental or other
factors. In addition, trauma, the loss of a loved one, a difficult relationship, or any other significantly stressful situation
may trigger a depressive episode. Subsequent depressive episodes may occur with or without an identifiable trigger.
There are a number of biological features that may distinguish Psychotic
Depression from Depression. The most significant difference may be the presence of an abnormality in the hypothalamic-pituitary-adrenal
(HPA) axis. The HPA axis, which is sometimes referred to as the stress hormone axis, appears to be chronically over-activated
in Psychotic Depression. Other abnormalities found in Psychotic Depression include sleep abnormalities and changes in other
areas of brain function.
How is Psychotic
Even Psychotic Depression is highly treatable. As is true of most medical
and psychological disorders, the earlier that treatment begins the more effective it is and the higher the likelihood that
recurrences can be prevented.
The first step toward getting help is to see your Primary Care Provider (PCP), the medical provider whom you see for other
disorders. Certain medications and medical conditions can cause the same symptoms as Psychotic Depression. Your PCP can rule
out these conditions by conducting a physical examination, asking questions, and/or ordering lab tests. If medications and
medical conditions can be ruled out, your PCP will then either render a diagnosis himself or refer you to a mental health
professional for further evaluation. Some PCPs are comfortable dealing with a Psychotic Depression themselves. However, in
the case of a Psychotic Depression your PCP is more likely to refer you for further evaluation.
A mental health professional
will conduct a complete diagnostic evaluation, including a discussion of any family history of depression and other psychological
disorders and a complete history of symptoms. This history will include when your depression started; how long you've been
depressed; how severely you're depressed; whether or not you've been depressed before; if so whether or not you received treatment
and how successful that treatment was; whether or not alcohol and/or substance abuse are involved; and whether or not you
feel suicidal and/or are planning to harm or kill yourself.
How is Psychotic Depression Treated?
Established Treatment Strategies
The most common established
treatment strategies are medication, Electoconvulsive Therapy (ECT), and psychotherapy. Antidepressant medications normalize
the functioning of neurotransmitters (chemical messengers), primarily serotonin and norepinephrine. These particular chemical
messengers are involved in regulating mood, although there's still no complete understanding of how this occurs. Antidepressant
medications include newer types, such selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake
inhibitors (SNRIs), and older types, such as tricyclics/tetracyclics (TCAs) and monoamine oxidase inhibitors (MAOIs). The
SSRIs include Prozac (fluoxetine), Celexa (citalopram), Zoloft (sertraline), and others; the SNRIs include Effexor (venlafaxine)
and Cymbalta (duloxetine); the TCAs include Tofranil (imipramine), Elavil (amitriptyline), Anafranil (clomipramine), and others;
the MAOIs include Nardil (phenelzine), Marplan (isocarboxazid), Parnate (tranylcypromine), and others.
Antidepressant medications can be effective in treating Psychotic Depression,
but people with Psychotic Depression often require a combination of an antidepressant medication and an antipsychotic medication.
This is reasonably effective, but tends to have a high incidence of side-effects, such as significant weight gain and sexual
dysfunction, and may take a long time to work. Antipsychotic medications, also referred to as neuroleptics and major tranquilizers,
normalize the functioning of dopamine, another neurotransmitter. Antipsychotic medications include newer types, such as the
atypical antipsychotics Clozaril (clozapine) and Risperdal (risperidone), and older types, such as the typical antipsychotics
Thorazine (chlorpromazine), Mellaril (thioridazine), Prolixin (fluphenazine), and Haldol (haloperidol).
ECT has a more reliable track record in improving symptoms than medication does
but the stigma, cost, and cognitive side-effects (memory loss) often make it a second or third choice for treatment except
in special circumstances. For example, if a patient's Psychotic Depression is imminently life-threatening as a result of suicide
risk and/or cachexia (loss of appetite and weight loss) ECT may be considered first. In addition, a patient who cannot tolerate
medications or who has responded well to ECT in the past may be considered for ECT first.
Regardless of which medication
might be prescribed, it takes several weeks to begin experiencing any effect and a few to several months to experience the
full therapeutic effect. DO NOT stop taking the medication unless you and the prescribing provider have agreed that it's appropriate
for you to do so, even if you feel better. Most people with Psychotic Depression who take a medication do so for two or three
years, and a small minority for longer. This is necessary so that the changes in neurotransmitter functioning which occur
in your brain as a result of taking the medication become permanent. In addition, abruptly stopping an antidepressant or antipsychotic
medication can cause unpleasant withdrawal symptoms and/or a relapse. If one medication
doesn't work, be open to trying another. People with Psychotic Depression who don't improve after taking one medication increase
their chances of getting better by switching to a different medication or adding a second medication.
Several types of psychotherapy (the "talking cure") can help people with Psychotic Depression.
Some are short-term (10 to 20 weeks) and others are long-term (more than 20 weeks). Which might be suitable for you can be
determined between you and the mental health professional whom you see. There are many types of psychotherapy, all of which
can be effective in treating Psychotic Depression, but two types, Cognitive-Behavioral Therapy (CBT) and Interpersonal Therapy
(IPT), have well-established histories of being effective. CBT helps people change negative and self-critical styles of thinking
and behaving that contribute to or worsen Psychotic Depression, replacing them with more positive, functional, and adaptive
ways. IPT helps people understand and work through dysfunctional and/or maladaptive relationships that contribute to or worsen
Psychotic Depression. For those with Psychotic Depression, psychotherapy alone is never the best treatment option. A combination
of psychotherapy and medication is almost always necessary.
Experimental Treatment Strategies
There are two promising experimental treatment strategies being researched at present: The use of glucocorticoid antagonists,
including mifepristone; and Transcranial Magnetic Stimulation (TMS). Glucocorticoid antagonists may treat the underlying cause of Psychotic Depression by correcting an overactive hypothalamus-pituitary-adrenal
(HPA) axis. By competitively blocking certain neurotransmitter receptor sites, these medications limit the effects of cortisol
on the brain.
Transcranial magnetic stimulation (TMS) is being
investigated as an alternative to ECT in the treatment of depression. TMS involves the administration of a focused electromagnetic
field to the cerebral cortex to stimulate specific nerve pathways. A number of early studies have shown promise of TMS in
treating Depression with few side effects. TMS does not require anesthesia and has not been associated with significant cognitive
deficits.How can you help someone with Psychotic Depression?
If you know someone with Psychotic Depression, odds are that his or her Depression affects you, too. The first and most important
thing that you can do to help a friend, family member, or coworker with Psychotic Depression is to help him or her get diagnosed
and treated. You might have to schedule an appointment on behalf of the person or even go with him or her to see a provider.
If he is actively psychotic, you may need to consider getting the help of law enforcement, the Court, a mental health professional,
and/or a community mental health program to have him hospitalized against his will. Encourage him to stay in treatment but
to seek different treatment if no improvement occurs after a few to several months of medication and/or psychotherapy.
- Offer emotional support, understanding, patience,
- Engage him in conversation
and, most importantly, listen nonjudgmentally.
- Never criticize or belittle feelings
he expresses, but rather point out realities and offer hope.
- Never ignore comments
about suicide. Encourage him to share these thoughts with his provider and/or mental health professional, and report them
yourself if you believe that he won't do so.
- Invite him to participate in walks,
outings, and other activities. Keep trying even if he declines, but don't push him to do too much too soon. Making him feel
as if you have too many expectations of him may inadvertently result in feelings of failure.
- Remind him that with time and treatment even Psychotic Depression will improve.
Dr. Thomas E. Hranilovich