Psychotic Depression Can Be Effectively Treated but is Often Tragically Missed

Anthony J. Rothschild, M.D., University of Massachusetts
Anthony J. Rothschild, M.D.

From The Quarterly, Summer 2011

Psychotic depression, which is major depressive disorder combined with psychotic delusions or hallucinations, often goes undiagnosed. The kinds of delusions that tend to typify this condition often involve fears, such as the loss of a home or supposed threats by the I.R.S., which may not be apparent as delusion to an attending psychiatrist. The patient may also not divulge his fears out of shame or distrust. Studies have estimated the prevalence of psychotic depression among people diagnosed with depression at anywhere from 14 percent to close to 50 percent. The higher percentage is found largely among geriatric patients.

In addition to psychosis, other symptoms more common in this form of depression include increased motor disturbances, either severe agitation or severe slowing up; cognitive impairment; feelings of guilt and hopelessness; hypochondria; anxiety and sleep disorders. The mortality rate from general medical causes is twice that of those with depression without psychosis, the reasons for which are still unclear, and the suicide rate is five times higher.

Dr. Rothschild is one of only a handful of psychiatrists in the United States who have made psychotic depression a focus of their research. Among his studies, he conducted a collaborative effort with three other medical centers which found that the illness was completely missed in the emergency room or the inpatient setting 27 percent of the time. One simple expedient he suggests is having a family member present to corroborate whether or not the patient really is being pursued by the IRS (or their other fears).

Two treatments are recommended for treating psychotic depression: an antipsychotic medication combined with an antidepressant or electroconvulsive therapy (ECT). Most of the time, however, the only treatment administered is an antidepressant, which studies have shown is ineffective. In another multisite study, Dr. Rothschild and team found that only five percent of a sample group of patients with psychotic depression were properly medicated. The irony is that despite the severity of the disorder, these patients can actually achieve complete relief when appropriately treated. However, since both of these treatment regimes involve potentially negative side effects, one of the questions Dr. Rothschild is currently interested in investigating is how long patients should be kept on treatment after their symptoms have abated.

Article comments

I have psychotic depression and most treatments only last a small amount of time before symptoms have come back. I have had delusions. Of hearing voices which seem to go away when my symptoms are gone however medications only last for a short while then my symptomes return and god knows i seriously need help. Though im am seeking treatment nothing seems to help so please help me and i feel im running out of oppostion so i would like to take part in the study so please help

I need help

I am affected with psychosis depression for six years and I greatly need your help.

Hello Dr. Rothschild,
Greetings! I live in Bangalore, India.
My wife is sufferring from Depression Psychosis. It is surfacing every two months and is greatly effecting our married life. Our child, 5yrs old is also greatly stressed by this. She is on medication but they do not seem to be effective enough. Is this a incurable disease? Please help!

Regards,
S.S

My son was diagnoss with psychotic depression almost a year ago he was hospitalized for 2weeks for pychosis and he was ok for almost 10 months, and now he is hearing voices again he has been on meds since he was out the hospital non stop don't understand why is this is happening again please help!

My sister has extreme phsycosis and ya,,,,,she hates me too cause of it:(

I had psychotic depression 1.5 years ago. Very traumatic, never want to go there again. Hospilised 5 weeks. Put on tricyclic, antipychotic, and ect. Read time and again ect OR antidepressant and antipychotic. Must have all three to recover AND maintain. My life is now calm, peaceful, content. Downside is weight gain and some memory issues. I'll be blunt: if you really want to recover and have a fulfilling life again, these side effects are no big deal. I'm alive now and loving it.

Please help, my companion of 27 years had a stroke two years ago and now he has developed psychosis. He is becoming depressed and threatens suicide, I have also noticed he has become slowed up and cannot maintain in the work place. Another problem is he cannot remember how to travel to certain places which he travelled on a regular basis. When I speak to him his mind does not hold what I am saying, can it be the start of alzheimers, he is fifty years old and very fit until the stroke 2 years ago.

I have to agree with the fact that this problem is missed by regular physicians and emergency room protocols. My wife has been in the hospital half a dozen times in the last six months. Only once did the ER Physician prescribe anything for anxiety. Problem is, that does not treat the Depression. What I want to stress here is that in our case the Somatic Symptoms, Shortness of Breath, Muscle Spasms and a host of other "physical" complaints preceded the delusions related to the illness. So, here's the guidance; When the physical symptoms increase rapidly, there is likely a mental psychosis that needs to be discovered. It will only get worse with time. So, if at all possible, do not delay getting experienced help. Clinical Psychologists and Psychiatrists are needed. You won't likely get such help through an Emergency Room, unless you ask for psychological help... which you should definitely do.

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