Navigating depression with psychosis

Psychosis is a set of mental health symptoms characterized by losing touch with objective reality. It’s usually associated with conditions like schizophrenia. But it can be a symptom of other mental health conditions as well. Even depression — one of the most common mental health conditions in the world — can sometimes come with symptoms of psychosis.

Living with symptoms of both depression and psychosis can be challenging. But with the right support and treatment, you can learn how to manage your symptoms. 

What is psychotic depression?

Psychotic depression, or major depressive disorder with psychotic features, describes when someone experiences symptoms of psychosis — like hallucinations and delusions — alongside depression. It’s not diagnosed as a distinct condition but rather as a subtype of major depression. It’s sometimes referred to as “depressive psychosis.” 

Research shows that up to 18% of people who go through a depressive episode experience symptoms of psychosis.

Psychotic depression vs. other types of depression

Psychotic depression is unique because it tends to be more severe than other types of depression. Although every type of depression is serious, psychotic depression comes with increased risks. For example, people with psychotic depression have double the risk of suicide* compared to people with other types of severe depression. 

Most of the time, people with depression don’t experience symptoms of psychosis. When psychosis is present, it can make diagnosis and treatment more complex. But with the right support, you can learn to manage symptoms of both.

*A note on safety: The 988 Suicide and Crisis Lifeline provides 24/7, confidential support with trained crisis counselors. If you or a loved one is in emotional distress or a suicidal crisis, please call or text 988. If you’re experiencing a life-threatening emergency or you need immediate help, please call 911.

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Symptoms of depressive psychosis

If you live with depressive psychosis, you experience symptoms of major depressive disorder and of a psychotic episode. 

Symptoms of major depression include:

• Persistent feelings of sadness, hopelessness, or emptiness
• Loss of interest or pleasure in activities you once enjoyed
• Fatigue or lack of energy, even after resting
• Changes in appetite, leading to weight loss or gain
• Trouble sleeping, such as insomnia or sleeping too much
• Difficulty concentrating, making decisions, or remembering things
• Feelings of worthlessness or excessive guilt
• Thoughts of death or suicide, or suicide attempts

Symptoms of psychosis include:

• Hallucinations, such as hearing voices or seeing things that aren’t there
• Delusions, or strongly held false beliefs that don’t align with reality
• Disorganized thinking, which makes it difficult to follow conversations or express thoughts clearly
• Paranoia or extreme distrust of others, even without evidence
• Difficulty functioning in daily life due to disorganized thoughts or behavior

People with depressive psychosis often experience hallucinations and delusions that are consistent with their depressed mood. For example, they might hear voices telling them they’re worthless or something terrible is about to happen. Other common mood-congruent hallucinations include hearing voices telling them to hurt themselves, smelling rotting flesh, or seeing monsters or dark figures. 

But other people could have mood-incongruent hallucinations and delusions, or opposite to what you’d expect from someone experiencing depression. For example, they might see a “guardian angel” protecting them or hear a voice telling them they have superpowers.

Schizoaffective disorder vs. psychotic depression

It’s also important to mention the diagnosis of depressive-type schizoaffective disorder. This is a mental health condition that’s characterized by depression as well as psychosis. The main difference between schizoaffective disorder and psychotic depression is that people with schizoaffective disorder experience psychosis independent of their depression symptoms. Even when they aren’t currently in a depressive episode, they could still have symptoms of psychosis.

If you disagree with your diagnosis, talk to your healthcare provider. Having the right diagnosis can be an important first step to getting the care you deserve.

Can depression cause psychosis?

Psychotic depression is diagnosed when you experience symptoms of psychosis only during a severe depressive episode. It’s unclear what about depression can lead to psychosis. It might have something to do with the way depression affects your brain. 

Researchers have found other factors that could increase your risk of developing depressive psychosis (versus depression without psychosis), including:

• Living alone
• Having contact with friends less than once per month
• Being unemployed
• Having no close confidants
• Childhood adversity
• Family history of psychosis

In addition, there could be a neurobiological component to psychosis. People who showed neurological soft signs — which are subtle symptoms reflecting neurological abnormalities, like poor motor skills or sensory difficulties — were also more likely to develop psychosis alongside depression.

Managing depression with psychosis

Depression and psychosis are both chronic conditions, which means they can’t be cured. But there are ways to successfully treat and manage the symptoms of both. Many people go into “remission” from mental health conditions, which means that their symptoms are so well-managed that they no longer affect their lives.

The first step to the right treatment is to get the right diagnosis. Unfortunately, research shows that psychotic depression is frequently misdiagnosed. Often, the psychotic features of depression get missed. So if you believe you experience psychotic symptoms alongside depression, let a healthcare provider know. The recommended treatment for depression with and without psychotic features can be different.

Some of the most effective treatments for psychotic depression include:

• Therapy: Therapy methods like cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT) can help you learn how to deal with triggers, keep your stress levels low, and adopt healthy coping skills. One specific treatment method called acceptance-based depression and psychosis therapy (ADAPT) has shown promising results when combined with medication.
• Self-care: When navigating the symptoms of psychotic depression, self-care can help, too. Things like getting enough sleep, moving in a way that brings you joy, eating nourishing foods, and surrounding yourself with people who care about you can all benefit your mental well-being. 
• Medication: Medication can help manage symptoms of both depression and psychosis, although there are no medications approved for this specific combination. 

It’s important to work with a qualified mental healthcare provider to determine a treatment plan that’s aligned with your specific needs and goals.

Find care with Rula

It can be frightening to experience hallucinations or delusions alongside depression symptoms. But you’re not alone, and help is available. A therapist can help you get access to the diagnosis and treatment that can help you overcome these symptoms and start to feel safe and happy again.

At Rula, we’re committed to delivering a comprehensive behavioral health experience that helps people feel seen and understood so they can get back to feeling their best. 

Rula makes it easier to find a licensed therapist or psychiatric provider who accepts your insurance so you don’t have to choose between affordable care and excellent care. With a diverse network of more than 15,000 providers, 24/7 crisis support, and appointments available as soon as tomorrow, we’re here to help you make progress — wherever you are on your mental health journey.

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