Can Major Depression Cause Psychosis? Recognizing and Treating Psychotic Symptoms

If your loved one has been diagnosed with depression and has begun to experience hallucinations or delusions, you may be questioning their diagnosis and wondering how you can move forward. So… can major depression cause psychosis? In a word, yes. Recognizing psychotic depression, however, requires understanding how psychotic symptoms of depression differ from those of primary psychotic disorders. It is also critical to acknowledge the unique dangers of psychotic depression and seek out comprehensive care that will allow your loved one to find a path to lasting recovery.

Depression is one of the most prevalent mental health disorders in the world, affecting an estimated 7% of adults in the United States each year. The symptoms of depression encompass a broad range of emotional and physical experiences, from pervasive sadness to fatigue to insomnia. These symptoms can vary widely in severity and affect each person in unique ways. While depression remains a relatively mild disorder with minimal functional impact for some, others experience severe, prolonged, and functionally debilitating manifestations of the illness that deeply disrupt their ability to live a healthy and stable life.

Today, there is more awareness than ever before about the true face of depression, thanks to an increasingly open public discourse surrounding mental illness. Sometimes, however, people with major depression experience perceptual distortions that cause them and their loved ones to question whether it’s truly depression they’re suffering from. Hallucinations and delusions, after all, are typically not on the lists of symptoms spoken in antidepressant commercial voiceovers. It can seem like a quite big leap to go from “not enjoying things you used to enjoy” to “hearing voices.”

Indeed, psychotic experiences can be disturbing both in and of themselves and because they can appear to be at odds with what you imagine depression to be. So, can major depression cause psychosis? How does psychosis impact your loved one’s prognosis? Exploring the answers to these questions can give you greater insight into what your loved is experiencing and how you can move toward recovery.

Recognizing Psychotic Depression


Although psychotic symptoms of depression are under-recognized, it is believed that approximately 20% of people with major depression will experience such symptoms during the course of their illness. These symptoms arise directly from the depression itself rather than as the result of a psychotic disorder such as schizoaffective disorder and generally represent a severe articulation of major depression. As such, psychotic depression is not a distinct diagnosis, but a subclassification of major depressive disorder.

The presentation of hallucinations and delusions in psychotic depression are distinct from those experienced by people with primary psychotic disorders in a number of important ways. One of the most critical distinctions is timing. For people with psychotic depression, depression precedes psychosis—and psychosis arises only in the presence of that depression.

“In depression with psychotic features, patients generally have a history of previous depressive episodes, and the current episode begins with classic depression that worsens over time, at which point psychotic symptoms emerge,” explains Dr. Albert H. C. Wong, Professor of Psychiatry at the University of Toronto. Conversely, if people with schizophrenia become depressed, they tend to do so only after psychotic episodes, when they gain the clarity to “realize the poor prognosis, loss of function, and dependence on caregivers.” In cases of schizoaffective disorder, on the other hand, mood episodes and psychotic episodes must occur both simultaneously and independently of each other, rather than solely occurring together.

The specific qualities of hallucinations and delusions experienced by people with psychotic depression also differ from those experienced by people with primary psychotic illnesses:

  • Often, psychotic symptoms are mood congruent, such as delusions that they will cause something bad to happen, that a loved one will die, or that their partner will leave them.
  • Auditory hallucinations often involve messages that they are a bad person, or even that they should kill themselves.
  • Some people also experience somatic hallucinations, such as putrid bodily smells resulting from undiagnosed medical conditions.

In such cases, psychosis tends to be an extension of depression, rather an indication of a primary psychotic disorder.

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The Dangers of Psychotic Depression


While all forms of severe depression can have a significant impact on quality of life and complicate prognosis, psychotic depression presents heightened risks. Grace Rattue writes, “The course of the disorder is linked to elevated rates of relapse and higher long-term psychosocial impairment, as well as higher mortality rates than [people with non-psychotic depression].” Although this can be explained in part due to the fact that people with psychotic depression tend to be clustered in the more severe end of the depression spectrum, it may also be attributed to the unique symptomatology of psychotic depression.

Psychotic symptoms can be deeply disturbing and functionally disruptive, impairing the ability to participate in positive, meaningful social relationships and vocational activities. People with psychotic depression are also more likely to experience symptoms such as rumination, insomnia, psychomotor disturbances, and cognitive dysfunction than people with non-psychotic depression, further compromising emotional wellbeing and functional ability. Additionally, psychotic depression is associated with a higher risk of developing bipolar disorder.

Unfortunately, psychotic depression frequently goes undiagnosed. While many families worry that their loved one with psychotic depression will be incorrectly diagnosed as having a primary psychotic disorder such as schizophrenia, data shows that clinicians are far more likely to overlook the psychotic features of the illness altogether. According to data from the National Institute of Mental Health Study of the Pharmacotherapy of Psychotic Depression, “27% of 130 diagnoses among a well-characterized sample of patients with a research diagnosis of psychotic depression were initially incorrectly diagnosed.” The vast majority of those were misdiagnosed as major depressive disorder without psychotic features.

Researchers point out that this rate of incorrect diagnosis is likely far lower than what would be found in in the general population, as patients with complex medical histories that could complicate diagnosis (such as a recent history of substance abuse) were excluded. “This finding suggests that the clinicians were missing the psychosis rather than the mood disorder,” says Anthony Rothschild, Professor of Psychiatry at the University of Massachusetts Medical School.

The widespread under-recognition of psychotic features in major depression may be the result of a variety of factors, including:

  • Reluctance on the part of the client to disclose psychotic experiences out of fear or shame;
  • The client failing recognize that what they are experiencing is a form of psychosis in the first place;
  • Clinicians failing to ask clients directly about psychotic symptoms, or failing to explain what constitutes psychosis in a way that allows the client to identify their symptoms as psychotic;
  • Clinicians themselves failing to identify symptoms of psychosis due to lack of understanding of the complexities of psychotic depression.

Whatever the reasons, the result is that many people who have major depression with psychotic features do not receive the care they need to heal and remain at heightened risk for poor outcomes.

The Need for Comprehensive Care


If you believe that your loved one is struggling with psychotic depression, it is essential to seek out in-depth psychological testing to achieve diagnostic clarity and implement an appropriate treatment plan. Typically, pharmacological interventions in the form of both antidepressants and antipsychotics will act as the cornerstone of this treatment. This combination treatment has been shown to alleviate symptoms more fully than antidepressants or antipsychotics in isolation and is considered the gold standard for the treatment of psychotic depression.

However, medication is only one part of the treatment picture. If your loved one has significant psychological and functional struggles, it is critical that they receive intensive psychosocial support in order to create lasting recovery and restore overall quality of life. For many, long-term residential treatment programs offer the best environment in which to participate in the kind, quality, and duration of therapies necessary to foster healing.

In a long-term residential treatment program, your loved one will be able to participate in a broad spectrum of therapies designed to help them address their unique challenges. Due to the close and trusting therapeutic alliances made possible in these environments, your loved one can more easily overcome internal barriers to disclosing psychotic symptoms, allowing their treatment team to gain a fuller picture of their psychiatric health. As a result, pharmacological treatment can be continuously modulated to ensure efficacy and tolerability.

Your loved one can also begin to explore their experiences, express themselves, and identify healthy ways of moving forward with the support of expert clinicians and compassionate peers. This is vital not only to manage the symptoms of psychotic depression but to address the ways those symptoms have impacted your loved one emotionally and functionally. In a safe, structured environment, your loved can gain the insight and skills to repair the damage created by their illness and move toward greater self-awareness, emotional tranquility, and independence.

Psychotic depression can be a frightening experience and presents special risks for your loved one. But by connecting with a treatment program with the expertise necessary to treat this complex condition, you can ensure that your loved one receives the care they need to create a stable, healthy, and purposeful life.

Hanbleceya offers long-term residential treatment for people struggling with mental health disorders as well as co-occurring substance use disorders. Contact us to learn more about our renowned San Diego-based program and how we can help you or your loved one start the journey toward recovery.