Depressive or Psychotic Symptoms

What depressive symptoms are

Depressive symptoms affect emotions, thinking and the body. The core symptoms are:

• Persistent low mood: sad, empty or tearful most of the day, nearly every day
• Anhedonia: loss of interest or pleasure in almost everything

Other common symptoms:

• feeling worthless or excessively guilty
• hopelessness about the future
• changes in sleep (insomnia or sleeping much more)
• appetite and weight change
• tiredness and low energy
• poor concentration and indecisiveness
• slowed movements and speech, or restlessness
• thoughts of death or suicide

When five or more of these are present most days for at least 2 weeks and impair functioning, doctors diagnose major depression.

What psychotic symptoms are

Psychosis means a person's thoughts and perceptions are disrupted so they have difficulty telling what is real.

• Hallucinations: hearing voices is most common; seeing, smelling, tasting or feeling things that are not there also occur.
• Delusions: firmly held beliefs that are clearly false and not shared by others in the person's culture, such as being followed, being controlled, having special powers, or that their body is rotting.
• Paranoia: intense suspicion that others intend harm.
• Disorganized thinking: jumping between topics, speech that is hard to follow.
• Disorganized or unusual behavior and reduced emotional expression.

Early warning signs before a first episode can include withdrawal, a drop in school or work performance, suspiciousness, poor sleep and unusual ideas.

When depression and psychosis occur together

Major depression with psychotic features

In severe depression, psychotic symptoms usually match the depressed mood ("mood-congruent"): delusions of guilt ("I have committed a terrible sin"), poverty or ruin, or illness, and voices that criticize or accuse. People may hide these beliefs, so asking directly matters. This form carries a higher suicide risk and needs combined treatment.

Bipolar disorder

In bipolar disorder, psychosis can appear in severe depressive or manic episodes. In mania, delusions are often grandiose.

Schizoaffective disorder

Schizoaffective disorder combines symptoms of schizophrenia with major mood episodes, but psychosis also persists for at least 2 weeks without mood symptoms.

Postpartum psychosis

Postpartum psychosis usually begins within the first 2 weeks after birth, with rapidly changing mood, confusion, hallucinations and delusions. It is a psychiatric emergency.

Other causes of psychotic symptoms

How doctors assess these symptoms

A first episode of psychosis or severe depression needs a thorough assessment:

• Mental state examination: mood, thoughts, perceptions, insight and risk of harm
• History from the person and, with consent, family or friends: onset, drug and alcohol use, medicines, family history, recent childbirth
• Physical examination
• Blood tests: blood count, kidney, liver and thyroid function, calcium, glucose, B12, and often HIV and syphilis tests
• Urine drug screen
• Brain imaging or EEG when there are neurological signs, an atypical course or late onset

Screening questionnaires such as the PHQ-9 help measure depressive symptoms.

Treatment

Depressive symptoms

• Talking therapies: cognitive behavioral therapy, behavioral activation, interpersonal therapy
• Antidepressants such as SSRIs, usually taking 2 to 6 weeks to work
• Exercise, sleep routine and social support as additions

Psychotic symptoms

• Antipsychotic medicines reduce hallucinations and delusions, often within days to weeks
• Early intervention in psychosis services offer coordinated care for first episodes, including family support, CBT for psychosis and help with work or school
• Avoiding cannabis and stimulants improves outcomes

Psychotic depression

Treatment combines an antidepressant with an antipsychotic. Electroconvulsive therapy (ECT) is highly effective and is used when the illness is severe, life-threatening, or not responding to medicines.

Hospital care

Hospital admission may be needed when someone is at risk of harming themselves or others, cannot care for themselves, or needs rapid treatment.

Outlook

With early treatment, most people recover from an episode of depression or psychosis. Some have recurrences and benefit from long-term treatment. Early help, staying on treatment and avoiding drugs reduce relapse.

Frequently asked questions

What is the difference between depressive and psychotic symptoms?

Depressive symptoms affect mood and energy: sadness, loss of interest, hopelessness, sleep and appetite change. Psychotic symptoms affect a person's sense of reality: hallucinations, delusions and disorganized thinking. They can happen separately or together in conditions such as psychotic depression and bipolar disorder.

Can depression cause psychosis?

Yes. Severe depression can include psychotic features, typically delusions of guilt, illness or ruin and critical voices. This is called major depression with psychotic features. It needs specialist treatment, usually an antidepressant plus an antipsychotic, or ECT, because suicide risk is higher.

What are the early signs of psychosis?

Early signs include withdrawing from friends and family, a drop in school or work performance, poor sleep, suspiciousness, unusual beliefs, difficulty concentrating, and hearing or seeing things others do not. Getting help early improves recovery.

Can drugs cause psychotic symptoms?

Yes. Cannabis, especially high-potency forms, amphetamines, cocaine, hallucinogens and alcohol withdrawal can all trigger psychosis. Some prescription medicines, such as high-dose steroids, can too. Drug-induced psychosis may settle when the drug is stopped but can unmask a lasting illness.

How do I help someone with psychotic symptoms?

Stay calm, listen without arguing about their beliefs, and encourage them to see a doctor. If they are at risk of harming themselves or others, call or text 988 (US) for crisis advice, or call 911 or your local emergency number in an emergency.