Today, I'm talking about psychotic depression and this is based on a couple of search questions query. Major depression is an illness where you can have a depressed mood or an irritable mood and some 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 every day and take care of things at home.
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The severely depressed person, though, may not be able to get out of bed although there are 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.
What are the early warning signs of psychosis?
These psychotic symptoms are delusions and hallucinations however, delusions tend to be more common than 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 on several occasions. I've seen people who were delusionally depressed and felt that people were coming into their homes. 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 could just be people going to work or 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 thoughts 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, that delusions are fixed false beliefs. For the delusional person, it's their truth, it's not just an opinion. It's a 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 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. 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. Do 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. Someone may be 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 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 no 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 rapidly 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.
Conclusion On Psychotic 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 to bring the psychotic symptoms under control. Make sure to always visit your doctor. 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 psychosis if it's present. That's psychotic depression. Always go to your doctor. I just give information about Psychosis.
