What is Psychotic Depression?

What is Psychotic Depression?

Hi, I’m Doctor Tracey
Marks, a psychiatrist and I make videos on
mental health education and self improvement. Today, I’m talking about
psychotic depression and this is based on a
couple of viewer questions. Major depression is an
illness where you can have a depressed mood or an irritable mood and a number of other symptoms
that affect your sleep, your appetite, energy level,
outlook on life and so on. You can be mildly to moderately
to severely depressed. We usually look at the
level of functioning to estimate the severity
of the depression. How are you functioning in
your personal, your work, and your school life? Someone who is mildly
depressed may have trouble getting out of bed and having
a hard time finding joy in things, but they
still go to work everyday and take care of things in the home. The severely depressed person, though, may not be able to get out
of bed despite the fact that there’s babies in
the house crying for food. Even having people or
finances depending on you isn’t enough to get you going. Why? Because it’s simply not a choice. When depression hits that
hard, it takes over your will. Some people will feel like
their limbs are too heavy to lift and we call this leaden paralysis. It’s not a real paralysis,
it’s a figurative term. Depression can also become
so severe that you lose touch with reality and develop
psychotic symptoms. These psychotic symptoms are
delusions and hallucinations, however, delusions tend to be more common than the hallucinations. The delusions can take on a
persecutory or nihilistic tone. Persecutory is when you
feel attacked in some way. You may feel like people
are talking about you or trying to harm you
and on several occasions, I’ve seen people who were
delusionally depressed and felt that people were
coming into their home. The evidence for this was
that they would see things in the house in different places. So if a glass was moved
from one table to the next, it meant that people were
coming into the house when no one was there. Another common persecutory
delusion that I’ve seen is feeling as though you’re being followed and each time I’ve heard this, the person would give me examples of how they would see certain cars driving at the same time each day or the blue car that was
parked down the street for several days in a row. Now, the cars driving at the same time just could be people going to
work or going to appointments at certain times each day or
you could have someone visiting and leaving their car parked on the street during their visit. Even though those are very
possible explanations, to the delusional person it’s evidence of some bigger sinister plot. Nihilistic delusions are
when you feel that things are senseless and
they’ve lost their value. Like what’s the point in life? Nothing matters. This can be some of the
thought behind a person not wanting to live and
making a suicide attempt. Sometimes suicide attempts are impulsive, but sometimes they’re born out
of these nihilistic delusions that nothing matters so
why does even anyone exist. Even existence is senseless. Keep in mind, delusions
are fixed false beliefs. For the delusional
person, it’s their truth, it’s not just an opinion. It’s fact that they think
everyone should believe and they don’t change just
because they hear a good argument against the belief. It’s fixed and no evidence to the contrary will make them believe differently. The delusions can resolve, though, eventually as the depression improves or with a medication intervention. This is different from the
psychosis that you would see with schizophrenia. With schizophrenia, the
delusions are not only present in the context of depression or even mania for that matter. I did a video explaining
schizophrenia in more detail. People with bipolar
disorder who become manic can also become delusional
as part of the mania, but in this case the delusions
tend to be more grandiose in nature. They can be persecutory,
but they still have this grand theme to it. So for example, you can feel
that people are following you because it’s just become
apparent that you’re related to the royal family. Or you can believe that
the government is involved in a plot, but it’s to use the
internet to wipe out society and, thereafter, you
because you’ve found a way to thwart their plans. You see the difference? With the depressed person,
behind their thoughts is sadness, hopelessness, or
fearfulness of being harmed. With the manic delusional
person, there’s this theme of power and purpose and
you’re at the center of it. One other point about the
delusions in the context of depression and mania. The delusions tend to be non-bizarre, meaning that they’re plausible. They’re not likely, but
they’re technically possible. It’s possible that someone
is letting themselves into your home when you’re
away and changing the position of your beverage glasses
to send you the message that you’re unsafe, but
people probably are not spending their time doing that. Whereas the delusions that
we see with schizophrenia tend to be more bizarre
in nature and implausible. An example of this is
believing that some entity is removing your organs
at night while you sleep and using them to sell overseas. Why is this implausible? Because we can’t live without our organs. That may seem obvious, but if you say this to the psychotic person, they may say, “Well that’s the whole secret. “We’re all living without organs “or without some of your organs “and you don’t just realize it “because they’re being
taken out little by little.” The delusions can get very convoluted. One of the difficulties with recognizing a psychotic depression is
that the thoughts can be such a part of how you
feel that you don’t realize that your thinking is off. If you’re feeling very
depressed and worthless, it doesn’t occur to you to
raise your hand and say, “My thinking has gotten so
extreme that I think people “are trying to harm me.” It just seems like a natural
progression of how you feel. Even people close to you
may not recognize the degree to which your thinking has
morphed into delusions. A psychotic depression
can happen at any age, but the incidence of it tends to increase as people get older, like 60 and beyond. How do we treat psychotic depression? Psychotic depression that occurs
within unipolar depression would be treated either
with antidepressants plus an antipsychotic medication or electroconvulsive therapy. Antidepressants would be medications like Fluoxetine,
Escitalopram, and Venlafaxine. Antipsychotic medication
examples are Quetiapine and Aripiprazole. If you go the medication
route, there’s not a set amount of time that you need to stay on the antipsychotic medication. You do need to stay on it
long enough to make sure that the psychotic symptoms
are not going to return. This usually means several months, probably around three to four months, and at that time, it’s
reasonable to taper off the antipsychotic medications, but stay on the antidepressant for a total of about six months to a year. Anything less than six
months and you’re at risk of having a return of
your depressive symptoms so you never want to start a medication, feel better in a month or two,
and then stop the medication because you feel better. It takes the brain
about six to nine months to recover from a depressive episode so I tend to keep people on
the antidepressant medication for nine months to a year. Then at that year mark, if all is well and things have been stable, I’ll taper them off of the antidepressant and see what happens. If they have a return in symptoms, I’ll restart the antidepressant
and get them back up to the previous dose that worked, then stay there and
try again another time. Maybe in six months to a year. I would not restart the
antipsychotic medication unless the person had a return
of the psychotic symptoms as well. Psychosis that occurs
inside of bipolar disorder, whether it’s the depressive
phase or the manic phase, is treated a little differently because you have to be careful about adding an antidepressant to someone with bipolar disorder. Antidepressants increase
the risk of triggering a manic episode or making
someone rapid cycle between phases. I talk about using antidepressants
in bipolar disorder in this video. So for the person who has bipolar disorder and becomes psychotic, you could use electroconvulsive therapy, the same as you would for
psychotic unipolar depression. For the medication option, you would add an antipsychotic medication if the person is on nothing. But if the person is already
on a mood stabilizer, you could still add an
antipsychotic medication to their current regimen. So for example, if the
person was taking Lamotrigine as a mood stabilizer,
you could add Quetiapine to the Lamotrigine. If the person was
already taking Quetiapine and still became psychotic, you could increase the Quetiapine or add a second antipsychotic medication for a temporary period of time to bring the psychotic
symptoms under control. I only mention Quetiapine as one example of an antipsychotic medication
that’s commonly used in bipolar disorder
for mood stabilization. But since it is an
antipsychotic medication, it also treats the
psychosis if it’s present. That’s psychotic depression,
thanks for listening. See you next time.

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Major depression is an illness where you can have a depressed or irritable mood and a number of other symptoms that affect your sleep, appetite, energy level, outlook on life and so on. You can be mildly to moderately to severely depressed.

We usually look at the level of functioning to estimate the severity of the depression. How are you functioning in your personal, work and school life? Someone who is mildly depressed may have trouble getting out of bed and have a hard time finding joy in things, but they still go to work everyday and take care of things in the home. The severely depressed person may not be able to get out of bed despite the fact that there are babies in the house crying for food. Even having people or finances depend on you isn’t enough to get you going. Why? Because it’s not simply a choice. When depression hits that hard, it talks over your will.

Depression can also become so severe that you lose touch with reality and develop psychotic symptoms. These psychotic symptoms are delusions and hallucinations. However, delusions tend to be more common than hallucinations. And the delusions can take on a persecutory or nihilistic tone.

Persecutory is when you feel attacked in some way. You may feel like people are talking about you or trying to harm you. Nihilistic delusions are when you feel things are senseless or they’ve lost their value. Like what’s the point in life? Nothing matters. And this can be some of the thought behind a person not wanting to live and making a suicide attempt. Sometimes suicide attempts are impulsive, but sometimes they’re born out of these nihilistic delusions that nothing matters so why does anyone exist? Even existence is senseless.

How do we treat psychotic depression?
Psychotic depression that occurs within unipolar depression would be treated with either antidepressants plus an antipsychotic medication or electroconvulsive therapy. Antidepressants would be medications like fluoxetine, escitalopram and venlafaxine. Antipsychotic medication examples are quetiapine and aripiprazole.
Psychosis that occurs inside of bipolar disorder whether it is the depressive phase or the manic phase is treated a little differently because you have to be careful about adding an antidepressant to someone with bipolar disorder. Antidepressants increase the risk of triggering a manic episode or making someone rapid cycle between phases. So for the person who has bipolar disorder and becomes psychotic. You could use electroconvulsive therapy the same as you would for psychotic unipolar depression. For the medication option you would add an anti-psychotic medication if the person is on nothing, but if the person is already on a mood stabilizer in you could add an antipsychotic medication to their current regimen.
Video about using antidepressants with bipolar disorder

Video about Schizophrenia

Disclaimer: All of the information on this channel is for educational purposes and not intended to be specific/personal medical advice from me to you. Watching the videos or getting answers to comments/question, does not establish a doctor-patient relationship. If you have your own doctor, perhaps these videos can help prepare you for your discussion with your doctor.