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Major Depressive Disorder Can Include Psychotic Features

Part 2: Identifying and understanding major depression subtypes.

Key points

  • Psychotic features are present in approximately 20% of major depressive episodes.
  • These psychotic symptoms only occur while the person is depressed.
  • Common psychotic symptoms in depression include voices saying negative things or delusions of not being sure if they are alive or dead.

In the previous post, readers were reacquainted with the basics of major depressive disorder (MDD). Today, we will start looking at the subtypes, beginning with major depression with psychotic features. This means that, while depressed, the person experiences hallucinations/delusions.

Estimates vary, but psychotic depression seems to be present in upwards of 20% of MDD patients and brings some challenges to treatment. Unfortunately, psychotic features are correlated with worse prognosis and morbidity, yet according to a top researcher on the topic, often go unrecognized (Rothschild et al., 2008; Rothschild, 2013).

A Review of Psychosis

Etymologically, the term psychosis means "abnormal condition of the soul (the essence of one's being)." This is most associated with schizophrenia, but psychotic symptoms occur across numerous disorders, as written about in The Many Faces of Psychosis.

Source: Beatriz/Pexels

While it is the primary feature of diseases in schizophrenia spectrum disorders, we may see delusions, hallucinations, and/or disorganized psychotic symptoms in depression, mania, some personality disorders, PTSD, and even some severe OCD presentations can have delusional material. Psychosis is also present in dementia and delirium.

While sometimes it will be obvious that the patient is experiencing psychosis, like talking to themselves and looking about, in other instances it may be more subtle. Perhaps the patient "has it together enough to know they don't have it together" and is able to hide it. After all, they're feeling bad enough being depressed, why would they want to let on that they're "crazy," too? This is where the clinician becomes the detective.

First, it is always a good idea to ask any new patient during their diagnostic interview about psychotic symptom experiences, even if it is not a presenting complaint. Cover your bases! Remember, patients don't necessarily know what hallucinations and delusions are, so don't point-blank ask, "Have you ever hallucinated or had delusions?"


Hallucinations are internally-generated sensory experiences. The person's mind is creating voices, sights, tastes, smells, and sensations. Most common are voices, followed by visual hallucinations. Hallucinations experienced by patients during major depressive episodes can include:

  • Voices saying demeaning things like, "You're no good and no one likes you!"
  • Commands to hurt/kill themselves.
  • Seeing demons or dark characters.
  • Seeing/smelling rotting flesh on their body.

The examples above are known as mood-congruent hallucinations. That's because they are related to the theme of depression. Occasionally, people experience mood-incongruent hallucinations, meaning the material has nothing to do with being depressed. An example of mood incongruent hallucinations during MDD would be voices saying random things. On the extreme end of incongruency, I recall one patient who, while clearly hallucinating, would have giggle fits despite being depressed.

Mood incongruent psychotic features are associated with poorer prognosis. While it's merely a hypothesis, one wonders if mood-incongruent material of a bright nature like the above patient could be the subconscious's way of trying to correct the depressed mood.

Diagnostic protocol dictates that we not only note if psychotic features are present, but also if they are mood-congruent or incongruent.

Assessing for hallucinations

To assess for hallucinations, a clinician might pose the question like this: "When you're awake, has anything ever happened where you thought you were experiencing, or maybe you were even sure you were experiencing, hearing, or seeing things that other people couldn't?"

It is preferable to say "when you're awake" because some interviewees, when I'd ask when the voices occur, replied, "well, in my dreams." I also find it important to ask if it sounds like their own voice, such as hearing themselves think, or if it sounds like someone is speaking to them, but nobody is there. More than once, it was clarified "hearing voices" meant their own train of thought.

If the patient says they have experienced hallucinations, a clinician can respectfully dig deeper by replying: "Thanks for being willing to share that with me. I know it might not be easy to talk about. Can you tell me when the last time the voices (or seeing things, etc.) happened?" Be sure to ask if they may occur any time, or, if the person is prone to depression, only during the times they're depressed.

This is important because, if hallucinations (and/or delusions) are reported as occurring regularly regardless of mood, then it could be more indicative of a schizophrenia-spectrum condition called schizoaffective disorder.

Next, it will help to follow up: "What can you tell me about the experience?" and let the patient fill you in rather than making them feel interrogated about it. It is often embarrassing for patients to admit to such things, and we don't want them to shut down. Rather, partner with them to learn about the experience and show you want to understand, because, there's a good chance they've felt entirely misunderstood if they have tried to share the experience before.

Lastly, be sure to clarify if the hallucinations ever include commands to harm themselves or others and if so, have they ever acted on them? How do they deal with such voices if they arise? Have they had any such voices today? If so, be sure to perform a risk assessment.

In the end, there is no need to panic if someone says they hear voices. Many people do and have learned to manage them well, even sans medications. Exploring that further is part of our job as treatment providers.


A delusion is a fixed, false belief that is held with conviction. In other words, even if everyone else knows the belief is not true, the patient is convinced of it. Some examples of mood-congruent delusions include:

  • The patient is not sure if they are alive or dead. This is called a nihilistic delusion.
  • They feel they are such a bad person that they deserve punishment and people are plotting to destroy them; a sort of paranoia.
  • They come to believe they're an evil entity or are possessed.

Assessing for delusions

Assessing for a history of delusional material can be a bit trickier than hallucinations, because delusions can take on so many forms and themes. If someone is not clearly delusional, that again does not mean we shouldn't try to assess for a history of the matter.

We can test the waters with inquiries such as, "At any point, did you ever fear things were happening in your life that you just couldn't explain? Like, maybe you felt you were under surveillance, or that special messages were being sent to you from the TV or radio?" If yes, asking them to explain their experience, as in evaluating for hallucinations, is the next step.

Keep in mind that, while it is a good idea to reality test, it is not a good idea to become challenging towards a delusional patient, especially if they are paranoid. They could feel that you're against them, too. Using the first example of a paranoid individual, a clinician might reply, "How did you discover this?" There is a good chance you'll receive a detailed description with indications it is delusional, like very irrational or hard-to-follow explanations, as noted in Detecting Delusional Disorder.

Other patients may choose to remain terse. Don't take it personally; it can be embarrassing for the person to discuss. Like hallucinations, if you discover a patient has a delusion that may lead to harming themselves or others, be sure to perform a risk evaluation.

Johannes Krupinski/Unsplash
Source: Johannes Krupinski/Unsplash

Treatment implications of psychotic features

Clearly, the presence of delusions and/or hallucinations brings additional, significant challenges to treatment. If a patient indeed has a history of psychosis while depressed, it is essential to inquire about the symptoms each session. It is not unusual for psychotically-depressed patients to require hospitalization, which you, as therapist, may be instrumental in organizing if they begin to present a heightened risk to self or others.

Even if a patient isn't psychotic at the moment, knowing if they have a history of becoming psychotic when depressed is important. At the first sign a depressive episode is setting in, it is a good time to encourage a visit to their psychiatrist to assess for use of an antipsychotic medication to augment their antidepressant, for example. In extreme cases, electroconvulsive therapy (ECT), which is explored more fully in an upcoming post in this series on melancholic features, may be necessary (e.g. Pinna et al., 2018; van Dierman et al., 2020). Ideally, we also will incorporate their family/friends by educating them on signs and having the patient agree to let them notify providers of concerns.

The next post on Thursday, Oct. 7, 2021, will feature the anxious distress specifier, another addition to MDD that is correlated to a higher risk of self-harm.


Pinna, M., Manchia, M., Oppo, R., Scano, F., Pillai, G., Loche, A.P., Salis, P., & Minnai, G.P. (2018). Clinical and biological predictors of response to electroconvulsive therapy (ECT): A review. Neuroscience Letters, 669, 32-42.

Rothschild, AJ. (2013). Challenges in the treatment of major depressive disorder with psychotic features. Schizophrenia Bulletin, 39(4), 787–796.

Rothschild AJ, Winer J, Flint AJ, et al. (2008). Missed diagnosis of psychotic depression at 4 academic medical centers. The Journal of Clinical Psychiatry, 69(8), 1293-1296. DOI: 10.4088/jcp.v69n0813

van Dierman, L., Poljac, E., van der Mast, R., Plasmans, K., Van den Ameele, S., Heijnen, W., Birkenhager, T., Schrijvers, D., & Kamperman, A. (2020). Toward targeted ECT. The interdependence of predictors of treatment response in depression further explained. The Journal of Clinical Psychiatry, 82(1).