![]() Patients who initially present with classic depression can develop psychotic symptoms, typically when the depression is severe. ![]() A reactive depression of this sort in schizophrenia is more likely when a psychotic episode has resolved and the patient has insight into his or her condition. Conversely, patients with primary psychotic illnesses such as schizophrenia can become depressed when they realize the poor prognosis, loss of function, and dependence on caregivers-much as with any chronic medical illness. In depression with psychotic features, patients generally have a history of previous depressive episodes, and the current episode begins with classic depression that worsens over time, at which point psychotic symptoms emerge. ![]() Patients with schizoaffective disorder have psychotic symptoms that persist with and without mood disorder symptoms. As a result, depressed and psychotic symptoms are usually thought of as being separate entities with different causes.Ĭlinically, the differential diagnosis rests primarily on the timing, progression, and overlap of psychotic versus depressive symptoms. 3 This approach has largely been maintained in DSM-5. 2 During the 19th century, Emil Kraepelin and others favored a separate category for schizophrenia and psychotic disorders with a mood component, such as bipolar disorder. 1 However, there has been ongoing debate in psychiatry about the diagnostic classification of psychotic and mood disorders. The comorbidity between mood and psychotic symptoms has been known since at least the second century, when Galen noted that patients with depression could also have delusional beliefs. This article reviews the distinction between depressive and psychotic symptom domains, current knowledge about the etiology and neurobiology of depression and psychosis, and how this knowledge can inform the treatment of patients with features of both. ![]() There is also increasing overlap in the medications used to treat these symptoms. While there are obvious differences between feelings of depression and associated neurovegetative symptoms, and the hallucinations and delusions of psychosis, there is accumulating evidence of shared causes. Patients often present with both depressive and psychotic symptoms, which can complicate diagnosis and treatment. ![]()
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