Psychotic Depression Case Study: How Care Helped Bring Back Clarity

Written By

Dr. Amar Shinde

Published on: 10 May 2025

Patient Information

• Age: 28
• Gender: Female
• Background: Recently married, working as a graphic designer, living in a small midwestern city.

History or Cause

The patient's long history of psychotic depression began in her late teen years but went unrecognised for many years. The patient's symptoms developed in the context of a traumatic event in early childhood, the unexpected death of her father. Loss was initially a source of sadness, and the patient was able to function normally for a time, but symptoms worsened while in their late 20s. 

Around the age of 27, the patient's depression increased in severity and began to be marked by disturbing hallucinations and delusions. These symptoms escalated over 6 months. She began to withdraw from her friends, work, and husband. She heard voices and saw things that were not there, which resulted in extreme anxiety. She started to feel intense paranoia, where she believed that everyone surrounding her was "out to get her." She was unable to focus on her job, and her relationships suffered. After one particularly severe episode, her family forced her to see a professional.

Diagnosis:

Upon a thorough psychiatric assessment that included multiple clinical interviews and assessments, the patient was diagnosed with Major Depressive Disorder with Psychotic Features (the commonly accepted name being Psychotic Depression). This diagnosis carries a great burden of mental illness and involves the patient having depressive symptoms, along with some psychotic symptoms, such as hallucinations or delusions. This diagnosis was provided to the patient after the psychiatrist ruled out other possible mental health conditions (such as schizophrenia and bipolar disorder) and confirmed that the patient had experienced a major depressive episode with psychotic features for at least two weeks.

Treatment

The treatment for psychotic depression involves a combination of pharmacotherapy and psychotherapy. The primary target is to treat the depressive symptoms and psychotic features of this illness, so that the patient can get back into a somewhat normal and stable frame of mind. They used a holistic approach to make sure that nothing was overlooked in their care plan.

Program:

1. Initial Stabilisation:
   Hospitalisation was the first step, largely because we wanted our patient to be safe, but also so that we could stabilise her condition. She was receiving inpatient treatment and undergoing intensive care. For the first two weeks, our overriding concern was to treat her psychotic symptoms of hallucinations and delusions with medication and to provide a safe place to observe her.
   
2. Medications:
   
   • Antidepressants: She was prescribed fluoxetine, a selective serotonin reuptake inhibitor (SSRI), for her depressive symptoms.
     
   • Antipsychotics: An atypical antipsychotic medication called quetiapine was started to address the psychotic symptoms.
     
   • The addition of medications helped stabilise her mood and lessen the strength of her delusions and hallucinations.
     
   • Part of the stabilisation process required frequent monitoring to determine proper dosage amounts as well as to observe any side effects of the medication.
     
3. Antidepressants: She was prescribed fluoxetine, a selective serotonin reuptake inhibitor (SSRI), for her depressive symptoms.
   
4. Antipsychotics: An atypical antipsychotic medication called quetiapine was started to address the psychotic symptoms.
   
5. The addition of medications helped stabilise her mood and lessen the strength of her delusions and hallucinations.
   
6. Part of the stabilisation process required frequent monitoring to determine proper dosage amounts as well as to observe any side effects of the medication.
   
7. Psychotherapy:
   The patient was also receiving psychotherapy in the form of Cognitive Behavioural Therapy (CBT) and Supportive Psychotherapy to address her distorted thinking, confront the negative emotions surrounding her depression, and learn coping strategies.
   
   • CBT helped her to confront her paranoid and delusional thoughts, which were rampant and distressing, challenging her beliefs and acknowledging discrepancies in her thinking that were representative of delusional thinking and paranoid ideation.
   • Supportive psychotherapy emphasised validating her emotions and reasoning, offering emotional support (particularly on the grief she had experienced with her father's death), and building a therapeutic rapport that enabled the patient to feel understood.
     
8. CBT helped her to confront her paranoid and delusional thoughts, which were rampant and distressing, challenging her beliefs and acknowledging discrepancies in her thinking that were representative of delusional thinking and paranoid ideation.
9. Supportive psychotherapy emphasised validating her emotions and reasoning, offering emotional support (particularly on the grief she had experienced with her father's death), and building a therapeutic rapport that enabled the patient to feel understood.
   
10. Family Therapy:
    Aside from individual therapy, family therapy was initiated to help develop an understanding of the patient's condition for her spouse and other family members.  This was essential in rebuilding trust and communication since the patient's symptoms had greatly disrupted her relationships.
11. Antidepressants: She was prescribed fluoxetine, a selective serotonin reuptake inhibitor (SSRI), for her depressive symptoms.
    
12. Antipsychotics: An atypical antipsychotic medication called quetiapine was started to address the psychotic symptoms.
    
13. The addition of medications helped stabilise her mood and lessen the strength of her delusions and hallucinations.
    
14. Part of the stabilisation process required frequent monitoring to determine proper dosage amounts as well as to observe any side effects of the medication.
    
15. CBT helped her to confront her paranoid and delusional thoughts, which were rampant and distressing, challenging her beliefs and acknowledging discrepancies in her thinking that were representative of delusional thinking and paranoid ideation.
16. Supportive psychotherapy emphasised validating her emotions and reasoning, offering emotional support (particularly on the grief she had experienced with her father's death), and building a therapeutic rapport that enabled the patient to feel understood.
    

Therapy

• Cognitive Behavioural Therapy (CBT): The patient received weekly CBT therapy, addressing distorted thoughts and irrational fears. This was essential in addressing the delusions and hallucinations that she was experiencing.
  
• Group Therapy: The patient attended group therapy two times a week to interact with others struggling with similar mental health difficulties. This gave her emotional support and normalcy to her feelings and helped combat feelings of isolation.
  
• Family Therapy: The patient involved family members to address the emotional burden that her condition placed on her family. They learnt how to give adequate support, provide a safe setting at home, and mitigate the stress of caregiving.

Improvements/Recovery Timeline:

• Week 1-2:
  The patient was admitted to the inpatient facility, where he was stabilised.  Medications were modified to decrease his psychotic symptoms. Initial relief of his delusions and hallucinations allowed him to begin to participate in therapy.
  
• Week 3-4:
  The patient began outpatient therapy, where the emphasis was on the treatment of depressive symptoms using cognitive behavioural therapy (CBT). The patient's hallucinations and paranoia were gradually decreasing. While the initial weeks were emotionally difficult, the patient began to feel better emotionally.
  
• Week 5-8:
  At this point in time, the patient had significantly improved. His hallucinations had decreased, and paranoia was lessening. His CBT sessions were promoting management of his depressive thoughts, and the family therapy was increasing communication with his family. The patient began to engage more with reality, desire to return to previous activities, and engaged in his job as a graphic designer.
  
• Week 9-12:
  The patient's depressive symptoms were significantly decreasing. He began to re-engage with friends and family, and his work performance was markedly improved. The medication had been adjusted for better efficacy, and the patient started to have a sense of clarity about his future.
  
• Week 13-16:
  By this time, the patient had made a striking recovery. Her psychotic symptoms were gone, and she had her depression under control. She was no longer experiencing any major negative thinking or paranoia. She was able to get back to socialising with people, and she said she was feeling more comfortable managing her emotional states.

Our Success

This patient's recovery gave her back control of her life. She was able to return to work and commence rebuilding her relationships, particularly her relationship with her spouse, whom the patient described as being impacted greatly by her state of being. She has experienced more hopeful feelings about her future than she ever thought possible and has found interest and pleasure in certain pastimes not available to her until now: travel and drawing. 

The patient stated that the therapy helped provide clarity regarding the trauma's long-term effects and its contribution to her psychological difficulties.

Family and Community:

This transformation for the patient was something that touched the lives of every member of her family. The husband, once troubled and helpless in the presence of his wife's hallucinations, has found enhanced communication with her. Where once the couple had been deeply disconnected emotionally, they were now emotionally connected. This fundamentally changed the family's quality of life.

The patient was also able to reconnect with her community, volunteer, and socialise with others facing mental health challenges. Her story and journey stand as evidence that recovery is possible through mental health treatment, even with an illness as severe as psychotic depression.

Future Steps:

The patient continues with regular group and individual therapy as well as medications. She is also actively involved with a local mental health support group, where she helps others who struggle with mental health issues. Helping one another is integral to keeping her sanity and wellness intact.

Dr. Amar Shinde

Dr. Amar Shinde, founder of Jagruti Rehab, is a renowned psychiatrist in India with over two decades of experience in mental health, addiction recovery, and neuropsychiatry, dedicated to holistic, compassionate patient care.