It can be tricky to identify accurately because people often don’t report psychotic symptoms due to fear, confusion, or shame. So, careful observation and a thorough clinical interview are essential.
Here’s how the diagnosis typically happens:
- Psychiatric interview
The clinician will ask detailed questions about:
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- Mood symptoms such as sadness, hopelessness, and lack of energy.
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- Duration and intensity of depressive symptoms.
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- Psychotic experiences (e.g., hallucinations or delusions).
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- Suicidal thoughts or behaviors.
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- Family history of mental illness.
Sometimes, psychotic symptoms are not volunteered unless specifically asked, especially if the person fears being judged or hospitalized.
Clinicians are trained to gently ask questions like:
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- “Have you ever heard voices when no one is around?”
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- “Do you ever feel like others are out to get you?”
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- “Do you feel you’re being punished or watched?”
- Assessment tools (optional)
While there’s no lab test or brain scan to directly detect psychotic depression, standardized tools and rating scales may help guide the diagnosis.
These include:
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- Hamilton Depression Rating Scale (HAM-D).
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- The Brief Psychiatric Rating Scale (BPRS) is used for psychosis symptoms.
These are not always used, but can provide structure in complex or unclear cases.
- Rule out other conditions
Before confirming the diagnosis, clinicians will exclude other possibilities, such as:
| Condition: | How it’s ruled out: |
| Schizophrenia. | Psychosis isn’t limited to mood episodes. |
| Bipolar disorder. | Presence of manic/hypomanic episodes. |
| Schizoaffective disorder. | Psychosis occurs independently of mood changes. |
| Substance-induced psychosis. | Drug use or withdrawal history. |
| Medical causes (brain tumors, thyroid issues, dementia). | Blood tests, brain imaging, and a physical exam. |
This is a crucial step, since treating the wrong condition can worsen the actual one.
- Diagnostic criteria (DSM-5)
According to the DSM-5, a diagnosis of major depressive disorder with psychotic features is made when:
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- The person meets the full criteria for a major depressive episode.
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- There are delusions and/or hallucinations present during the depressive episode.
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- The psychotic features are either:
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- Mood-congruent (guilt, shame, disease, poverty, worthlessness).
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- Mood-incongruent (less common, e.g., bizarre delusions unrelated to mood).
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If psychotic symptoms exist outside depressive episodes, the diagnosis shifts to something like schizoaffective disorder instead.
- Involvement of family or caregivers
When someone is too unwell to fully describe their experiences, input from family members or caregivers can be extremely helpful.
They might notice signs such as:
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- The person talking to themselves.
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- Extreme paranoia.
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- Refusal to eat due to delusional beliefs.
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- Sudden social withdrawal.
Why an accurate diagnosis matters
Psychotic depression is more severe and carries a higher risk of suicide, self-neglect, and hospitalization than non-psychotic depression.
It also requires different treatment, typically a combination of antidepressant and antipsychotic medication, or ECT in severe cases.
–> My comprehensive guide about psychotic depression can be found here.
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