This is a very distressing condition where people often describe feeling black and empty, unable to think or feel.  Suicidal thinking is related to the profound feeling of despair and feeling of self-punishment.

Symptoms of psychotic depression can be summarised as:

  • Observable severe depressed mood
  • Severe social impairment
  • Severe psychomotor disturbance (agitation, retardation, cognitive processing problems)
  • Psychotic features such as delusions and/or hallucinations.

If a patient is very agitated, assume psychosis.  Those with psychotic depression usually don’t recover on an antidepressant alone.

Diagnosis of psychotic depression

Psychotic features:  consistent with mood (mood congruent) or mood incongruent.  Delusions more common than hallucinations (90% vs. 10%).

  • Pathological guilt: common in psychotic depression
  • Psychomotor disturbance: profound
  • Cognitive function: mild cognitive processing problems through to pseudo-dementia.

Useful questions

Some additional useful questions which can help to determine if a patient is suffering from psychotic depression include:

  • Are you a good person? Do you feel guilty? Do you deserve to feel like this?
  • Are you being punished or do you feel you are being punished for something you have done?
  • Are you being watched?  Are you being poisoned?
  • Do you have voices telling you that you are bad … or deserve to be punished… or should kill yourself / someone else?
  • Do you have something physically wrong with you? Can you please explain your concerns to me? What evidence do you have?


In psychotic depressions, hospitalisation may be indicated. ECT is very effective in treating psychotic depression – and is often the treatment of first choice, particularly if used successfully in previous episodes. It is not the option of last resort. If ECT is not appropriate, the treatment is a ‘broad-action’ antidepressant in
combination with an atypical antipsychotic. It is advised patients routinely take Omega-3 in conjunction with the medication. The antidepressant may be ‘dual-action’ (SNRI) or ‘broader-action’ (TCA). If the combination of SNRI and antipsychotic is of insufficient benefit, the next medication option is (after an adequate wash-out period) to change the SNRI to a TCA.

Once the psychotic features have lifted, antipsychotic medication may be gradually ceased (continuation can be associated with significant side-effects). The antidepressant is usually required for an extended period. Ensure there have been therapeutic levels of the medication for an adequate period of time before deciding that medication has not been successful and moving on to ECT.

Non-medication treatment – in the early stages, psychotherapy is generally of little benefit. It may be useful at a later stage to explore impact on work and family and other recovery issues. There may be a place for CBT for depression, anxiety management and understanding personality style. Examination of issues and working on self-management strategies are important in preventing future depression, improving resilience and maximising the individual’s psychological wellbeing.



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