Depression with psychotic features is when someone experiences both depression and psychosis. Psychosis refers to a disconnection from reality.

Major depression with psychotic features is also sometimes referred to as psychotic depression. It is a grave illness characterized by a combination of unipolar major depressive symptoms and psychosis.

Some estimates suggest that 14.7 to 18.5 percent of people with major depression may experience psychotic features and that the prevalence rates may rise with age.

This form of depression is an underdiagnosed and undertreated condition.

We focus here on unipolar depression, so the term major depression refers to a major depressive episode and not bipolar disorder.

This article will discuss how specialists diagnose depression with psychosis, as well as outlining treatment options and steps to recovery.

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Psychotic depression is an underdiagnosed form of depression.

Major depression is one of the most common mental health conditions in the United States.

According to the National Institute of Mental Health (NIMH), an estimated 4.3 percent of adults in the United States had at least one major depressive episode in 2016.

Depression with psychosis is when a person has depression and also experiences a disconnection from reality, which is called psychosis.

Experts also refer to depression with psychosis as depression with psychotic features.

Major depression affects mood, behavior, and various physical functions, such as sleep and appetite.

The symptoms of major depression include:

  • persistent feelings of extreme sadness, anger, or irritability
  • feelings of hopelessness or helplessness
  • feelings of worthlessness
  • loss of interest in once pleasurable activities
  • changes in appetite
  • changes in sleep, such as sleeping too much or too little
  • fatigue, or general lack of energy
  • difficulty concentrating, making decisions, or remembering things
  • recurrent thoughts of death or suicide

Psychosis means that a person feels disconnected from reality. It occurs when someone experiences things that are not reality, such as hallucinations or delusions.

People must remember that psychosis is a symptom of particular mental health conditions, not a disorder in itself.

Experiencing psychosis can be frightening and confusing, and psychosis can present in a variety of ways.

Symptoms of psychosis include:

  • delusions, also known as false beliefs or false perceptions
  • hallucinations, or seeing or hearing things that are not present
  • paranoia
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Changes in a person’s sleep pattern can be a symptom of depression.

Most diagnostic guides categorize psychotic depression as a subset of major depressive disorder. In the mental health field, there is an ongoing debate about whether this is accurate.

The International Classification of Diseases (ICD), 11th Edition, considers psychotic depression to be the most severe subtype of major depressive disorder.

The Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) also lists psychotic features as a subset of major depression. But psychotic features are not indicators of severity of major depression in the DSM-5.

Healthcare professionals can misdiagnose depression with psychotic features as other disorders. These other illnesses may include:

  • major depressive disorder without psychotic features
  • schizoaffective disorder
  • depression not otherwise specified
  • mood disorder

A misdiagnosis is often due to a lack of recognition of the psychotic features of major depression.

A mental health professional who is licensed to diagnose must decide if someone has psychotic depression.

These specialists will conduct a physical examination and may perform blood or urine tests to rule out other possible medical problems.

The mental health professional will also ask about an individual’s symptoms and medical history.

If the person has a family history of bipolar disorder, the doctor may screen for manic episodes.

To be diagnosed with major depressive disorder, a person will have a major depressive episode, including at least five symptoms that lasts at least 2 weeks.

Doctors diagnose depression by looking at the following symptoms:

  • depressed mood, loss of interest or pleasure
  • sleeping too much or too little
  • changes in appetite
  • low energy
  • difficulty thinking, concentrating, or making decisions
  • agitation or irritability
  • guilt
  • recurrent thoughts of death or suicide

To be diagnosed with psychotic depression, a person must exhibit symptoms of major depression, as well as symptoms of psychosis, such as:

  • delusions
  • hallucinations
  • paranoia

Depression with psychosis is a very serious medical condition that requires immediate medical attention.

As a result of psychosis, the risk of suicide is significantly higher in people with psychotic depression as compared to people with nonpsychotic depression.

If a person is or knows someone who is experiencing any of the symptoms listed above, they should speak to a healthcare provider immediately.

If someone is having thoughts of harming themselves or others, they can either call 911 (in the U.S.) or go a hospital emergency room.

In the U.S., they can also reach the National Suicide Prevention Lifeline at 1-800-273-8255. Trained staff are available 24 hours a day, 7 days a week.

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Typically, a doctor will prescribe an antidepressant, antipsychotic, or a combination of both.

There is some debate around the best treatment process for psychotic depression, particularly regarding first- and second-line treatments.

First-line treatment usually involves a combination of antidepressant and antipsychotic medications, or monotherapy, which refers to the use of either antidepressants or antipsychotics alone.

Doctors typically reserve electroconvulsive therapy (ECT) for second-line treatment, and specialists may use it if different medications have not helped to alleviate symptoms.

Psychotherapy, or talking therapies, can also help people, as a supplemental treatment for depression with psychosis.


A psychiatrist may prescribe a combination of antidepressant and antipsychotic medications. Different antidepressants affect different neurotransmitter pathways.

Common forms of these drugs include serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs).

Doctors often prescribe antidepressants alongside first- or second-generation antipsychotics.

Research suggests that the combination of antidepressant and antipsychotic medications is more effective than either of the two medications alone.

Some antidepressant and antipsychotic combination treatments include:

  • Venlafxine (Effexor) and Quetiapine (Seroquel)
  • Sertraline (Zoloft) and Zyprexa (Olanzapine)
  • Fluoxetine (Prozac) and Zyprexa (Olanzapine)

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is a medical procedure performed under anesthesia, in which a doctor, usually a psychiatrist, applies electrical currents to a person’s head, inducing a generalized seizure in the brain.

The treating prescriber may refer a person to electroconvulsive therapy (ECT) if they do not respond to medication-based treatments.

Electroconvulsive therapy is a safe and effective treatment for people with psychotic depression.

Psychosis can lead a person to hold a distorted view of what others perceive to be reality. The delusions or hallucinations associated with psychotic depression can lead to a medical emergency, which needs immediate medical attention.

A person may need to spend some time in the hospital, followed by an inpatient or outpatient treatment program.

Doctors are still trying to establish the most effective treatment for depression with psychosis.

Treatments focus on reducing or managing symptoms. Currently, no treatments can entirely cure psychotic depression. This means that people will usually need on-going treatment.

If people follow a treatment program, the long-term outlook for depression with psychosis is good. Medication or ECT can help manage even the most severe symptoms of psychotic depression.

Although treatments can reduce psychotic and depressive symptoms, they can also have side effects that may include the following:

  • drowsiness
  • dizziness
  • trouble sleeping (insomnia)
  • weight gain or weight loss
  • short-term memory loss

If someone is worried that they or somebody they know may have depression with psychosis, they should speak with a healthcare provider, as soon as possible. People often respond well to treatments and make a good recovery.