Mood Disorder, or Mad Disorder?

June 15, 2007 — -- The elderly woman with depression is convinced God is punishing her for having sinned in her youth through sexual improprieties. The middle-aged depressed man believes he deserves to die because he (inaccurately) thinks he has mismanaged his family's finances and will leave them destitute. The young woman with depression hears voices telling her she is no good and should kill herself.

Depression is officially classified as a mood disorder, and, indeed, people with depression typically experience major changes in their mood, often feeling sad, down, numb, empty or hopeless.

But sometimes people with depression go mad, as in crazy, or to use the technical lingo, psychotic.

At one level, this underscores that clinical depression is not the same thing as merely feeling down in response to having had a bad day or a bad week. Rather than merely being the blues that we all have from time to time, depression can involve a break with reality, as when someone experiences hallucinations, such as hearing voices when no one is around or seeing things when nothing is there, or delusions, irrational beliefs of the kind noted above.

These symptoms of madness, these psychotic symptoms, are common in the mood state we call mania, which is the high pole of bipolar disorder, occurring in more than half of this type of disordered mood. But they also occur in a smaller proportion of depressive mood episodes: Most studies say about 15 percent of them.

How are these psychotic depressions different from other depressions? As you may guess, adding psychosis to the picture means even more difficulties for people who are already battling depression; as confirmed by William Coryell, at the University of Iowa, and his colleagues when they studied people with psychotic depression over a period of 10 years.

In a study here at John Hopkins that will soon be published in the journal Bipolar Disorders, my colleagues and I studied 4,724 people with mood disorders to see whether psychotic depression was more common in people with bipolar disorder than in those with depression only.