Understanding Psychotic Depression

Major depression with psychotic symptoms (ICD-10) or psychotic features (DSM-IV) is relatively common and probably underdiagnosed. In recent years, there has been a renewed interest in better understanding the psychopathology of this disorder and in proposing more specific approaches. The DSM-5 provides a definition of psychotic symptoms that is independent of any concept of psychosis. In depressed patients, the presence of hallucinations or delusions, whatever their clinical form, generally leads to a diagnosis of psychotic depression and the prescription of neuroleptics. Psychotic symptoms are subdivided by the DSM into "congruent" or "incongruent" to mood. Psychotic depression is a severe form of so-called classic depression. It involves the presence of usual depressive symptoms, such as deep sadness, significant sleep disturbances, a feeling of intense hopelessness. In addition, it is accompanied by psychotic symptoms, such as hallucinations, delusions. Perceptual disorders such as illusions, erroneous interpretations are also described. The last two decades are rich in explorations of the genetics of psychotic disorders and allowed us to better understand their genetic architecture. The combination of psychosis and depression makes the daily life of those affected by it particularly difficult. Treatment is based on a pharmacological prescription combining antidepressants and antipsychotics, which is not a consensus. It is possible to treat psychotic depression with an antidepressant alone. However, in some cases, it may be necessary to perform electroconvulsive therapy (ECT) sessions under general anesthesia. Finally, psychotherapy is strongly recommended. The debate remains open regarding the need to associate an antipsychotic or the choice of the antidepressant. ECT remains an efficient treatment but is not practiced in many countries due to population reluctance.