Psychotic depression

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?