Psychiatric Associates

Psychotic Depression

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What is Depression?

       Depression is more than just feeling sad, blue, or down in the dumps for a few days. It can last weeks, months, or years and, without treatment, can seriously interfere with your ability to function properly. Someone who’s depressed experiences one or both of the following symptoms most of the day, nearly every day:
  • depressed mood (feeling sad, blue, down in the dumps, empty, helpless, and/or hopeless);
  • and/or anhedonia (an inability to experience pleasure, enjoyment, and/or happiness).
       He or she also experiences at least three of the following symptoms nearly every day:
  • decreased or increased appetite and/or significant weight loss or gain;
  • difficulty falling asleep and/or staying asleep, and/or waking up too early;
  • sleeping much longer at night, napping during the day, and/or fighting off falling asleep during the day;
  • mental and physical excitation, racing thoughts, flight of ideas, and/or restlessness;
  • thinking and moving as if you’re in slow motion;
  • fatigue and/or loss of energy;
  • feelings of worthlessness and/or guilt;
  • difficulty thinking, concentrating, and/or deciding;
  • and/or recurrent thoughts of death and/or suicide, a suicide plan, and/or a suicide attempt.
What is Psychotic Depression?
       Psychotic Depression occurs when someone experiencing Depression also experiences delusions or hallucinations. Delusions are false beliefs that usually involve a misinterpretation of perceptions or experiences and that are held onto despite what almost everyone else believes and despite undeniable and obvious proof to the contrary. Delusions can be about:
  • jealousy (your sexual partner is cheating);
  • erotomania (someone famous and/or important is in love with you);
  • grandiosity (you're someone special or powerful, have special knowledge, or have a special relationship with someone famous and/or important);
  • control (someone is controlling your feelings, impulses, thoughts, and/or actions);
  • reference (your TV or radio is talking to and/or about you);
  • persecution (you or someone close to you is being attacked, harassed, cheated, persecuted, and/or conspired against);
  • somatic (your body and/or how it functions has changed in some way);
  • thought broadcasting (your thoughts are being broadcast out loud so that others can hear them);
  • and/or thought insertion (someone's inserting thoughts into your mind).
       Delusions can be:
  • bizarre (that your internal organs have been removed and replaced with someone else's without leaving any wounds or scars);
  • nonbizarre (that you're under surveillance by the FBI);
  • mood-congruent (consistent with depression -- personal inadequacy, guilt, disease, or deserved punishment; or with mania -- inflated worth, power, knowledge, or special relationships to famous and/or important people);
  • and/or mood-incongruent (not consistent with depression or mania -- persecutory delusions, thought insertion, thought broadcasting, and delusions of being controlled).
       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 and/or unpleasant);
  • 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).

What causes Psychotic Depression?

       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 Depression diagnosed?

       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, and encouragement.
  • 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.

© 2010
Dr. Thomas E. Hranilovich
Licensed Psychologist

Psychiatric Associates / 4084 Okemos Rd. / Suite A / Okemos, MI 48864
Phone: (517) 347-4848 / Fax: (517) 347-4844