Psych · General adult psychiatry — mood disorders
Psychotic depression
Also known as Major depression with psychotic features · Delusional depression · Depressive episode with psychotic symptoms · MDD with mood-congruent psychotic features · MDD with mood-incongruent psychotic features · Psychotic major depressive disorder
Exam-exhaustive fellowship reference on major depression with psychotic features — DSM-5-TR/ICD-11 framing, mood-congruent vs incongruent content, elevated suicide risk, combination antidepressant plus antipsychotic evidence (STOP-PD, STOP-PD II, Spiker, Cochrane), ECT, differentials from schizophrenia-spectrum and organic psychosis, metabolic monitoring, and maintenance after remission. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Active suicidal intent, plan, command hallucinations, or delusional drivers of self-harm (guilt, deserved death, nihilism) — escalate care intensity immediately
- Food or fluid refusal, severe psychomotor retardation, mutism, or catatonic signs — urgent medical support and early ECT pathway
- Antidepressant monotherapy left as 'the plan' for established psychotic depression — treat both poles (AD+AP or ECT)
- Missed organic differentials: delirium, autoimmune encephalitis, endocrine crisis, substance-induced psychosis
- Missed bipolarity — prior mania/hypomania changes formulation and long-term mood stabilisation
- Olanzapine/quetiapine metabolic harm unmonitored; abrupt antipsychotic withdrawal soon after combination-induced remission (relapse risk)
Meet the patient
A 68-year-old retired accountant has not eaten for three days. She is convinced she has bankrupted her family, that the pension office is preparing charges, and that her bowel has stopped working and is rotting inside her.[10][12]
Her GP started sertraline six weeks ago. Nobody asked about the delusions, because she never volunteered them and she is very polite.[9][12]
She is slowed, quiet, and rated "settled" on the last nursing shift. That word is the most dangerous thing in her file.[10]
References18ShowHide
- [1]Meyers BS, Flint AJ, Rothschild AJ, Mulsant BH, Whyte EM, Peasley-Miklus C, et al. A double-blind randomized controlled trial of olanzapine plus sertraline vs olanzapine plus placebo for psychotic depression: the study of pharmacotherapy of psychotic depression (STOP-PD) Arch Gen Psychiatry, 2009.PMID 19652123
- [2]Flint AJ, Meyers BS, Rothschild AJ, Whyte EM, Alexopoulos GS, Rudorfer MV, et al. Effect of Continuing Olanzapine vs Placebo on Relapse Among Patients With Psychotic Depression in Remission: The STOP-PD II Randomized Clinical Trial JAMA, 2019.PMID 31429896
- [3]Kruizinga J, Liemburg E, Burger H, Cipriani A, Geddes J, Robertson L, et al. Pharmacological treatment for psychotic depression Cochrane Database Syst Rev, 2021.PMID 34875106
- [4]Wijkstra J, Lijmer J, Burger H, Cipriani A, Geddes J, Nolen WA Pharmacological treatment for psychotic depression Cochrane Database Syst Rev, 2015.PMID 26225902
- [5]Spiker DG, Weiss JC, Dealy RS, Griffin SJ, Hanin I, Neil JF, et al. The pharmacological treatment of delusional depression Am J Psychiatry, 1985.PMID 3883815
- [6]Rothschild AJ, Williamson DJ, Tohen MF, Schatzberg A, Andersen SW, Van Campen LE, et al. A double-blind, randomized study of olanzapine and olanzapine/fluoxetine combination for major depression with psychotic features J Clin Psychopharmacol, 2004.PMID 15232326
- [7]Wijkstra J, Burger H, van den Broek WW, Birkenhäger TK, Janzing JG, Boks MP, et al. Treatment of unipolar psychotic depression: a randomized, double-blind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine Acta Psychiatr Scand, 2010.PMID 19694628
- [8]Farahani A, Correll CU Are antipsychotics or antidepressants needed for psychotic depression? A systematic review and meta-analysis of trials comparing antidepressant or antipsychotic monotherapy with combination treatment J Clin Psychiatry, 2012.PMID 22579147
- [9]Ohayon MM, Schatzberg AF Prevalence of depressive episodes with psychotic features in the general population Am J Psychiatry, 2002.PMID 12411219
- [10]Gournellis R, Tournikioti K, Touloumi G, Thomadakis C, Michalopoulou PG, Christodoulou C, et al. Psychotic (delusional) depression and completed suicide: a systematic review and meta-analysis Ann Gen Psychiatry, 2018.PMID 30258483
- [11]UK ECT Review Group Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis Lancet, 2003.PMID 12642045
- [12]Malhi GS, Bell E, Bassett D, Boyce P, Bryant R, Hazell P, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391
- [13]Kennedy SH, Lam RW, McIntyre RS, Tourjman SV, Bhat V, Blier P, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments Can J Psychiatry, 2016.PMID 27486148
- [14]Kroenke K, Spitzer RL, Williams JB The PHQ-9: validity of a brief depression severity measure J Gen Intern Med, 2001.PMID 11556941
- [15]Keller J, Flores B, Gomez RG, Solvason HB, Kenna H, Williams GH, et al. Cortisol circadian rhythm alterations in psychotic major depression Biol Psychiatry, 2006.PMID 16458262
- [16]Schatzberg AF Anna-Monika Award Lecture, DGPPN Kongress, 2013: the role of the hypothalamic-pituitary-adrenal (HPA) axis in the pathogenesis of psychotic major depression World J Biol Psychiatry, 2015.PMID 24933348
- [17]Nelson JC, Papakostas GI Atypical antipsychotic augmentation in major depressive disorder: a meta-analysis of placebo-controlled randomized trials Am J Psychiatry, 2009.PMID 19687129
- [18]Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report Am J Psychiatry, 2006.PMID 17074942