Dr Sanil Rege covers the symptoms of severe depression with a focus on melancholic and psychotic features in depressive disorder.

Melancholic and psychotic depressions are both severe forms of depression associated with a high degree of morbidity and suicide risk. Features of Severe melancholic and psychotic depression:

• Psychomotor disturbance
• Impaired cognitive functioning (involvement of frontal-subcortical circuits)
• slowing of mental and motor activity
• Physical symptoms, e.g. constipation, menstrual irregularities, lowered BP
• Ruminations – themes of hopelessness, pessimism, self-accusation, self-derogation, feelings of inadequacy and of being a failure
• Periods of agitation
• More significant biological and genetic determinants than psychosocial
• Shows a minimal response to placebo
• Shows a superior response to biological treatments such as broad-spectrum antidepressant medication and electroconvulsive therapy rather than to psychotherapy.
• Psychotic depression presents with delusions: nihilistic, obsessional guilt, poverty and hypochondriacal are common themes

Patients with psychotic depression have double the risk of dying than non-psychotic depression and higher odds of completed suicide. [Vythilingam M et al., 2003]., [Gournellis R et al., 2018]

Psychotic depression is best conceptualised as melancholic depression with psychotic features (e.g. delusions, hallucinations, guilty ruminations).

Treatment principles: 

Treatment requires broad-spectrum antidepressants in melancholic depression and augmentation strategies as second and third-line treatments.

Psychotic depression requires antidepressants and antipsychotics as initiating treatments.

More detail on melancholic and psychotic depression.