Clinical Symptoms and Treatment of Severe Depression – Melancholic and Psychotic Depression
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 (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
👉Show 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 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
Read more on melancholic and psychotic depression: https://psychscenehub.com/psychinsights/melancholic-and-psychotic-depression-diagnosis-and-management/
23 Comments
Amazing video.
This video really helped me understand some symptoms of mental illness that I'm currently going through, so thank you so very much.
i’ve been dealing with depression for 12 years and am coming to terms with probably having to manage it for the rest of my life. This video has been helpful in many ways!
One, it has helped me see how closely related my physical symptoms of hypothyroidism and minstrel irregularities are interconnected with my depression. It should be no surprise when you think about how the body is so closely interconnected with itself — it makes sense that its maladies could be and probably are as well. This video was a good reminder of that.
Two, it has restrengthened my faith in the medicines I am taking and in my doctors. It has re-inspired me to take my medicines more faithfully, specifically the thyroid medicine which i have been failing to take for a while. When I saw T3 and T4 listed as a treatment to possibly compliment BSAs it was a real wake up call for me, as that is exactly what my thyroid medicine provides.
Three, watching this video helped me separate myself from my negative thoughts and obsessive guilt tripping i put myself through because it puts those thoughts into perspective as a symptom of a condition instead of absorbing them as facts and letting them bring me down. It (at least temporarily) halted those thoughts in their tracks and set my thoughts on a different track that is more hopeful, positive, and encouraging. For sure, I will save this video and watch it again when I need help getting out of that spiral. Another tool in the toolbox, they say.
Four and lastly, I love learning the science behind everything and this video very much appeals to that side of me.
Thank you so much for making this and sharing it with us! It is very appreciated!
Thank you so much!
Great video. I was diagnosed with severe depression with melancholic and psychotic features and put on a TCA and an antipsychotic, working like a charm and I have my life back. If you're interested, back in the olden days they distiguished between Melancholic depression and Atypical depression and used Amitriptyline (and nortriptyline) for Melancholic depression and the MAOI's for Atypical depression. This was before the advent of SSRI's/SNRI's etc. For me, Amitriptyline and Nortriptyline worked for melancholic depression when nothing else did. I truly believe Amitriptyline and Nortriptyline are the cure for Melancholic depression, however like you say if you have psychosis it's a good idea to add an AP in at the beginning.
Holy hell the intro is like an instant migraine generator
I looked into it and saw some of these can be OTC. I want to get it for my partner because she doesn't have health care of any kind and is struggling financially. How do you suggest these should be taken? I found
Pamelor and Amitriptyline in 1-rx-store and would like to know your input.
You're missing one very important part in the treatment of psychotic depression. Eliminating environmental psychosocial stressors comes FIRST before EVERYTHING else.
I was diagnosed with this sort of stuff, i kept telling doctors it was something physically wrong. They implied that i must have a very severe delusion. Turns out i had a IgE wheat allergy. Took the wheat out of my diet, after the spasming stopped i had a full recovery. Brain fog lifted. Just saying…. doctors are sometimes wrong.
Dr Rege I have 2 questions. You state that if agitation is there, then do have a high suspicion for psychosis and anti psychotics may have to be introduced earlier. Would the anti-psychotic be introduced earlier with a broad-spectrum antidepressant or without a broad spectrum antidepressant? You state that if “an antidepressant is prescribed, please do monitor for akathisia or worsening of agitation as it can be linked to poor outcomes”. Could you please expand on what you mean by this? Are your saying antidepressants can worsen MDD with Melancholic Depression and Psychotic Features causing akathisia? What type of antidepressants cause akathisia and what is the treatment if we see symptoms of akathisia (like rambling thoughts) after prescribing SSRI antidepressants to patients with psychotic depression?
My husband is currently in the mental hospital, has been 5 months since he had Covid 19, he says he knows his Covid 19 has caused his mental illness but the doctors look at him like he is stupid whenever he says that. And now they have him on so many medications that he has akathesia and they don’t believe him when he says he has akathesia because he don’t have much movement with it. So now he has just pretended to feel better for a couple weeks now so he could come home. But I am worried!! To my knowledge Akathesia is a very distressing feeling.
I THOUGHT HIS NAME WAS DR. SNAIL RAGE
Wish I had seen this before diving into TMS. Gave relief but shortlived. Healthy old guy, think I would be safe with high dose TCA?
Thank you so much for this education Dr.
We have begun in US accelerated TMS 10 treatments a day for 5 days theta burst. Any idea if that comes close to ECT?
Hello Dr.
Talking from personal experience those worry ruminating obsessive guild thoughts e.t.c and hypodriasis wouldn't be reduced without an ssri. It would get worse with a tricyclic antidepressant. It would cause more agitation. A better aproach would be an ssri with lithium or seroquel. I'm curious why you believe norepinephrine and dopamine would reduce agitation and obsessive thoughts since instead of increasing it. I would appreciate your answer
Thank you in advance. Is ECT effective when there may be an issue with dopamine receptors in the brain? Pre Parkinson’s perhaps
From my reading, bipolar depression seems to be melancholic. Are these depressions, melancholic and psychotic many times bipolar, seeing that mood stabilizers and anti-psychotics useful in treatment? Thanks
Great job 👏👏👍👍
Hi Dr. I have this kind of depression. I am taking Setraline 50mg and 50 mg amitriptyline and olanzapine at night would that be ok?
How about waking at 4am with anxiety and agitation and it becomes better at night.
Oh for fuck sakes!! No shit, been living with this for 18 months. With immense fear and FND symptoms such as tinnitus, visual snow, afterimages, disequilibrium and SI’s.
I know there is something really wrong with me, my rational brain is not working properly and fear network is overactivated.
I cannot tolerate SSRI/snri, they help with depression, but also increase dopamine in mesolymbic pathway and give me fear and agitation related FND – visual disturbances, gait problems, vestibular disturbances, chronic pain, etc.
What is a good method to reduce excess dopamine in mesolymbic pathway? Which for me is causing excitation in amygdala and loss of frontal cortex control.
Pardon me for asking, none of the clinicians in our Canadian network know anything.
I’m also overmethylated psychotic/schizophrenia spectrum. Severe adversity to SSRI (methyl donor) and great response to benzos.
I have scattered white matter HI’s on my MRI.
Wow! Great information, thanks🌷