Yesterday, we got reacquainted with Major Depressive Disorder (MDD) in general. Today, we will start looking at the subtypes, or specifiers, beginning with Psychotic Features. Estimates vary, but psychotic depression seems to be present in upwards of 20% of MDD patients and bring new 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:

Psychosis is a word that stems from the Greek psy, meaning “of the mind” and osis, meaning “abnormal condition of.” The word essentially equates to “out of touch with reality.” This is most associated with Schizophrenia, but psychotic symptoms occur across numerous disorders. 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 are 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 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. Some common hallucinations experienced by patients prone to them during Major Depressive episodes include:

  • Voices saying demeaning things like “you’re no good and no one likes you!”
  • Commands to hurt themselves
  • Seeing demons or dark characters
  • Seeing and smelling rotting flesh on their body

The examples above are known as mood congruent hallucinations- they are related to the theme of depression. Some people experience mood incongruent hallucinations. An example of mood incongruent hallucinations during MDD would be voices telling the person positive things about themselves, or that they have superpowers. Mood incongruent psychotic features are associated with poorer prognosis. While it’s merely a hypothesis, perhaps mood incongruent hallucinations are the subconscious’ 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?”

I preface with “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 willing to share that with me. I know it might not be easy to talk about. Can you tell me whenthe 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. If hallucinations (and/or delusions) are reported as occurring regularly regardless of mood, then it could be more indicative of a Schizophrenia-spectrum condition.

Next, I like 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, 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 to begins believing they are a “black angel” and friends and family must keep their distance, or they’ll contaminate them, and they’ll die. Such a delusion is likely rooted in intense guilt of being burdensome to others and negative feelings towards themselves to the point they feel evil.
  • 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 are sure people are following them to ambush them at the right time; a sort of paranoia.
  • They feel they are an awful husband or wife, and therefore believe their spouse must therefore cheating on them.

Can you come up with some examples of what mood-incongruent delusions may be in a depressed patient? Feel free to share in blog comments!

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 follow-up questions like the above, such as asking them to explain their experience, is the next step.

While it is a good idea to do some reality testing, it is not a good idea to become challenging towards a delusional patient, especially if they are paranoid. They could feel you’re against them, too. Using the first example of the “black angel” a clinician might reply, “How did you discover this?” There is a good chance you’ll get a rather detailed description, indicating this is their reality and the delusion is solidified for the time being. Others 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.

Treatment implications:

Clearly, the presence of delusions and/or hallucinations bring additional, significant challenges to treatment. It is not unusual for psychotically-depressed patients to require hospitalization, which you, as therapist, may be instrumental in organizing if they have 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 prescriber to assess for use of an antipsychotic medication to augment their antidepressant and ride out the storm, nipping it in the bud.

It is all about prevention, if possible. Given therapists usually see their patients more often than other providers, they are the first to notice symptom onset and worsening severity, so are essential in advocating for and orchestrating adjunctive treatments to psychotherapy. If a patient indeed has a history of psychosis while depressed, it is essential to inquire about the symptoms each session.

Tomorrow’s post will feature the Anxious Distress specifier, another addition to MDD that contributes higher risk of self harm.


Rosthschild, AJ. Challenges in the treatment of major depressive disorder with psychotic features. Schizophrenia Bulletin, Volume 39, Issue 4, July 2013, Pages 787796.

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