Hi, I'm Doctor Tracey Marks, a psychiatrist
and I make videos on mental health education
and self improvement.
Today, I'm talking about psychotic depression
and this is based on a couple of viewer questions.
Major depression is an illness where you can have
a depressed mood or an irritable mood
and a number of other symptoms that affect your sleep,
your 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, your work,
and your school life?
Someone who is mildly depressed may have trouble
getting out of bed and having a hard time finding joy
in things, but they still go to work everyday
and take care of things in the home.
The severely depressed person, though,
may not be able to get out of bed despite the fact
that there's 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.
These psychotic symptoms are delusions and hallucinations,
however, delusions tend to be more common
than the 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 and on several occasions,
I've seen people who were delusionally depressed
and felt that people were coming into their home.
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
just could be people going to work or going to 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 thought 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, delusions are fixed false beliefs.
For the delusional person, it's their truth,
it's not just an opinion.
It's 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 a 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.
I did a video explaining schizophrenia in more detail.
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.
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.
It's possible that someone is 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
a 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 not a 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 rapid cycle
between phases.
I talk about using antidepressants in bipolar disorder
in this video.
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.
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 of time
to bring the psychotic symptoms under control.
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 the psychosis if it's present.
That's psychotic depression, thanks for listening.
See you next time.