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Psychotic major depression (PMD) is a type of depression that can include symptoms and treatments that are different from those of non-psychotic major depressive disorder (NPMD). PMD is estimated to affect about 0.4% of the population (or one in every 250 people). Many people with psychotic depression experience delusions, which are beliefs or feelings that are untrue or unsupported.
PMD is sometimes mistaken for NPMD, schizoaffective disorder, schizophrenia or other psychotic disorders. Bipolar patients may experience PMD during depressed states. PMD is usually episodic, lasting for a defined amount of time, but in some cases can be chronic. PMD has unique biological features, which have led to innovative treatments. While PMD is often treated with a combination of antidepressants and antipsychotics, researchers have been developing new treatments that address the pathophysiology of PMD more directly.
Currently, PMD is considered a severe form of major depression, but patients with mild or moderate depression may still have psychotic features. Many people with PMD experience delusions, which are beliefs or feelings that are untrue or unsupported. Paranoid delusions or delusions of guilt may be the most common psychotic symptoms in PMD. Patients with PMD often have concerns that people are paying special attention to them or are trying to persecute them. Patients who experience delusional guilt may believe that they are being punished for past misdeeds or are responsible for problems they couldn’t possibly be responsible for.
Other common delusions include those in which people are concerned that something is terribly wrong with their bodies and physical health, when actually there isn’t anything wrong. Unlike other psychotic disorders, the delusions in PMD may not be very obvious. Delusions appear to be more common than hallucinations in PMD, but some people with PMD do hallucinate, or see or hear things that others do not. Auditory hallucinations (sounds) are perhaps the most common hallucinations seen in PMD. While other patients may report seeing, touching or smelling things that are not there, it is less common.
Other symptoms that are common in PMD are agitation, difficulty falling asleep, and frequent waking during the night. In addition, patients with PMD may have a greater suicide risk than patients with NPMD. Finally, those with PMD may have greater cognitive deficits (e.g., memory problems) than those with NPMD.
The course of PMD may be helpful in distinguishing it from other disorders. Most PMD patients report having an initial episode between the ages of 20 and 40. Over a lifetime, it appears that PMD patients experience an average of 4 to 9 episodes. As with NPMD, the episodes of PMD tend to last for a certain amount of time and subside. While PMD can be chronic (lasting more than 2 years), most PMD episodes last less than 24 months. Unlike psychotic disorders such as schizophrenia and schizoaffective disorder, patients with PMD generally function well between episodes, both socially and professionally.
History of treatments
Before electroconvulsive therapy (ECT) was invented in the 1930s, it was frequently observed that patients experiencing delusions with depression had poorer response to medication treatment. ECT seemed to have similar effects for depressed patients both with and without psychotic symptoms. The interest in psychotic depression increased after tricyclic antidepressants (TCAs) became available, because while NPMD responded to TCAs, PMD did not. In the past 40 years there has been a renewed interest in PMD. The FDA is considering a special class of drugs for the treatment of PMD as researchers learn more about the biology of the disease.
Many studies have suggested that PMD differs from MDD in treatment response. PMD is less likely than MDD to respond to placebo and to the use of only an antidepressant or an antipsychotic. The combination of an antidepressant and an antipsychotic appears to be necessary for the treatment of PMD. Early studies suggest an 80-90% response rate in PMD with combination treatment.