Major depressive psychosis (MDP), also known as psychotic depression, is a complex and severe mental health condition characterized by the co-occurrence of major depressive symptoms and psychotic features, such as hallucinations or delusional thinking. The condition is a subtype of major depressive disorder and is associated with a higher risk of suicide, prolonged illness duration, and significant functional impairment compared to non-psychotic depression. Globally, it is estimated that psychotic features occur in approximately 14–20% of patients with major depression, though prevalence rates may vary depending on diagnostic criteria and population characteristics (Ohayon et al., 2002). Despite its clinical severity, MDP often remains underrecognized and undertreated, especially in low- and middle-income countries, where mental health services may be inadequately resourced.

In India, mental health infrastructure is evolving, yet significant gaps remain in the detection, diagnosis, and treatment of complex psychiatric conditions such as MDP. Social stigma, limited public awareness, and shortage of trained mental health professionals contribute to delays in care. Furthermore, psychotic features in depressive disorders are frequently misdiagnosed as schizophrenia or bipolar disorder, resulting in inappropriate treatment strategies. Indian studies on MDP remain limited in scope and number, particularly in terms of treatment response and short-term outcomes in hospital-based settings (Srinivasan et al., 2004; Reddy et al., 2000). There is a pressing need for evidence-based data on effective therapeutic combinations and management approaches for MDP within the Indian context.

Recent advancements in psychopharmacology and neurobiological understanding of depression have led to the evolution of treatment protocols involving the combined use of antidepressants and antipsychotics, and in some cases, electroconvulsive therapy (ECT). However, treatment outcomes are influenced by a variety of factors, including patient adherence, comorbidities, severity of psychotic symptoms, and access to care. Tertiary care hospitals provide a unique opportunity to study these parameters due to their multidisciplinary setup and access to specialized resources. This study aims to fill the knowledge gap by examining the clinical profile, therapeutic interventions, and treatment outcomes of patients diagnosed with MDP in a tertiary care hospital in Bangalore, thereby contributing to a more informed and structured approach to managing this serious psychiatric condition.

Objective

The primary objective of this study was to evaluate the clinical presentation, therapeutic strategies, and short-term treatment outcomes among patients diagnosed with major depressive psychosis (MDP) in a tertiary care hospital setting in Bangalore. By assessing a cohort of patients diagnosed using standardized criteria, the study aimed to identify the most effective combinations of pharmacological and non-pharmacological interventions, including the use of selective serotonin reuptake inhibitors (SSRIs), atypical antipsychotics, and electroconvulsive therapy (ECT). In addition, the study sought to explore treatment adherence patterns between inpatient and outpatient settings, investigate demographic and socio-clinical correlations, and generate evidence-based recommendations to inform clinical practices in similar urban healthcare environments in India.

The study was conducted at a tertiary care hospital in Bangalore over a ten-month period from April 2018 to December 2018. Patients were included based on the diagnosis of Major Depressive Disorder with psychotic features according to the DSM-IV-TR criteria. Inclusion criteria encompassed individuals aged 18–65 years who provided informed consent and did not have a history of bipolar disorder, schizophrenia, or any substance-induced psychosis. Patients with major neurological conditions or comorbid severe physical illnesses were excluded. Ethical clearance was obtained from the institutional ethics committee prior to initiation.

A structured clinical interview was administered by qualified psychiatrists using the Structured Clinical Interview for DSM Disorders (SCID). Baseline demographic and clinical data were recorded, along with prescribed treatments and progress monitored over a 12-week follow-up period. Data collection tools included standardized case record forms and the Hamilton Depression Rating Scale (HDRS) for evaluating symptom severity. Treatment adherence, symptomatic improvement, and the role of pharmacotherapy versus ECT were assessed. Statistical analysis was performed using SPSS version 22. Descriptive statistics were used to summarize the findings, and inferential tests such as Chi-square and independent t-tests were employed to examine associations, with p < 0.05 considered statistically significant.

Study Design: A prospective observational study conducted at a tertiary care hospital in Bangalore from April 2018 to December 2018.

Inclusion Criteria:

• Patients aged 18–65 years
• Diagnosed with major depressive disorder with psychotic features as per DSM-IV-TR criteria
• Willingness to participate with informed consent

Exclusion Criteria:

• Presence of comorbid neurological disorders
• Substance-induced psychosis
• History of schizophrenia or bipolar disorder

Data Collection Procedure: Clinical diagnosis was made by trained psychiatrists using the Structured Clinical Interview for DSM Disorders (SCID). Treatment data, socio-demographic variables, and outcomes were recorded using a standardized data sheet. Patients were followed for 12 weeks.

Statistical Data Analysis: Data were analyzed using SPSS v22. Descriptive statistics summarized demographic and clinical variables. Chi-square tests and t-tests were used to assess associations. A p-value < 0.05 was considered statistically significant.

A total of 92 patients were included. The mean age was 35.2 years; 56 (61%) were female. The most common presenting symptoms were auditory hallucinations (67%), delusions (54%), and suicidal ideation (48%).

Pharmacotherapy included SSRIs (fluoxetine, sertraline) in 63%, atypical antipsychotics (risperidone, olanzapine) in 78%, and tricyclic antidepressants in 12%. ECT was used in 18% of patients, primarily those with catatonia or suicidal risk.

Patients on combined SSRI-antipsychotic regimens showed faster recovery (mean Hamilton Depression Rating Scale (HDRS) score reduction of 12.3 points, p<0.01). Treatment adherence was higher in inpatients (87%) compared to outpatients (59%).

Table 1: Demographic Profile of Participants

Table 2: Clinical Features and Symptoms

Table 3: Treatment Modalities Administered

Table 4: Clinical Response (HDRS Score Reduction)

Table 5: Treatment Adherence and Outcome

Figure 1: Age and Gender Distribution

Figure 2: Frequency of Clinical Symptoms

Figure 3: HDRS Score Reduction Across Treatment Modalities

Combined SSRI and antipsychotic treatment yielded the most favorable response with a mean HDRS score reduction of 12.3. The addition of ECT in severely affected patients (18%) further improved outcomes. Patients admitted as inpatients had significantly higher adherence rates and better symptom resolution.

The predominance of female patients and their mean age in our sample is consistent with existing research, which suggests that women are more likely to experience major depressive episodes with psychotic features (Rabheru et al., 1997). The high prevalence of psychotic symptoms such as auditory hallucinations and delusions aligns with earlier Indian studies (Srinivasan et al., 2004), reinforcing the need for clinicians to be vigilant in identifying and differentiating psychotic features in depressive episodes. These symptoms significantly influence the course of treatment and prognosis and require immediate intervention.

Our findings underscore the importance of combination therapy. Patients who received a regimen of SSRIs and atypical antipsychotics exhibited the most significant reduction in HDRS scores. This supports existing global evidence advocating for dual pharmacological interventions in psychotic depression (Nelson et al., 2007; Wijkstra et al., 2005). Moreover, the use of ECT in treatment-resistant or severely suicidal patients proved beneficial, contributing to rapid clinical stabilization, which is consistent with the UK ECT Review Group’s findings (2003). Despite its effectiveness, ECT remains underutilized in India due to stigma, lack of trained personnel, and limited infrastructure.

The adherence rates observed in this study also present an important insight. Inpatients were more likely to adhere to treatment protocols compared to outpatients, which might be attributed to structured environments and supervised medication intake. This emphasizes the necessity of psychoeducation and close follow-up for outpatient care. Additionally, our study reflects the advantages of tertiary care facilities in managing severe mental health conditions through multidisciplinary approaches, which might not be feasible in smaller or rural setups.

Another important observation is the impact of socioeconomic and educational status on treatment engagement and understanding of illness. Patients with higher education levels tended to show better adherence and understanding of their diagnosis and treatment plans. This calls for culturally adapted mental health literacy programs to bridge the awareness gap among populations with limited educational backgrounds.

These findings reinforce the effectiveness of early diagnosis and intervention, tailored pharmacotherapy, and appropriate use of ECT. However, challenges remain, particularly in ensuring continuity of care post-discharge and addressing the stigma associated with psychiatric illnesses. More research, especially multi-centric studies with larger and more diverse samples, is needed to generalize these findings and to guide policy formulation for mental health services in India.

This study had several limitations that need to be considered when interpreting the results. First, the relatively small sample size and single-center setting limit the generalizability of the findings to broader populations. Second, the follow-up period of 12 weeks may not have been sufficient to assess long-term treatment outcomes, including relapse and functional recovery. Third, adherence rates and some clinical variables were based on patient self-report, which may introduce recall or response bias. Additionally, the lack of a control group and randomization limits causal inference regarding the effectiveness of specific treatment regimens. Future studies with a larger, more diverse cohort, extended follow-up, and a randomized controlled design would be valuable in validating these findings.

Acknowledgment

We extend our gratitude to the Department of Psychiatry, [Hospital Name], Bangalore, for their support, and to all the patients and families who participated in this study.

This study highlights the clinical and therapeutic challenges involved in managing major depressive psychosis in a tertiary care hospital in India. Our findings demonstrate that a structured treatment approach, particularly one that combines SSRIs and atypical antipsychotics, can lead to significant improvements in symptom severity. The use of ECT further enhanced outcomes in treatment-resistant or acutely suicidal patients, underscoring its continued relevance in psychiatric care. The data also revealed that inpatient care resulted in better adherence and symptomatic relief, highlighting the role of closely monitored treatment environments.

Going forward, mental health services in India should prioritize early detection and the integration of multi-modal treatment strategies to optimize patient recovery. Enhanced mental health literacy, reduced stigma, and stronger follow-up systems, particularly in outpatient settings, are essential to improving long-term outcomes. Policymakers should consider bolstering infrastructure and training programs for ECT and other interventions in public healthcare systems. Further longitudinal and multicenter studies are necessary to validate our findings and inform evidence-based practices in the treatment of psychotic depression in diverse clinical settings.

Financial support and sponsorship: No funding sources.

Conflicts of interest: There are no conflicts of interest.

1. Rabheru, K., & Persad, E. (1997). A review of antidepressant use in the elderly. Canadian Journal of Psychiatry, 42(6), 489-494.
2. Reddy, Y. C. J., et al. (2000). Treatment of depression in India: An overview. Indian Journal of Psychiatry, 42(3), 195-200.
3. Srinivasan, T. N., et al. (2004). Recognition of depression in primary care in India. International Journal of Social Psychiatry, 50(4), 295-302.
4. Ohayon, M. M., & Schatzberg, A. F. (2002). Prevalence of depressive episodes with psychotic features in the general population. American Journal of Psychiatry, 159(11), 1855-1861.
5. Nelson, J. C., et al. (2007). Atypical antipsychotic augmentation in major depressive disorder. Journal of Clinical Psychiatry, 68(6), 874-880.
6. Wijkstra, J., et al. (2005). Pharmacological treatment for psychotic depression. Cochrane Database of Systematic Reviews, (4).
7. UK ECT Review Group. (2003). Efficacy and safety of electroconvulsive therapy in depressive disorders. Lancet, 361(9360), 799-808.
8. Thirthalli, J., et al. (2010). Prospective comparison of short-term outcome in first-episode psychosis. Acta Psychiatrica Scandinavica, 121(5), 356-365.
9. Schatzberg, A. F., et al. (1990). Nortriptyline and perphenazine in psychotic depression. Archives of General Psychiatry, 47(1), 19-25.
10. Flint, A. J., et al. (1997). Psychotic features in late-life depression. Journal of Affective Disorders, 46(3), 255-260.
11. Meyers, B. S., et al. (1992). Treatment of psychotic depression in the elderly. Biological Psychiatry, 31(3), 193-202.
12. Coryell, W., et al. (1984). Major depression with psychotic features: A comparative study. American Journal of Psychiatry, 141(8), 999-1003.
13. Greden, J. F. (2001). The burden of recurrent depression. Journal of Clinical Psychiatry, 62(Suppl 22), 5-9.
14. Rush, A. J., et al. (2006). Sequenced treatment alternatives to relieve depression (STAR*D). American Journal of Psychiatry, 163(11), 1905-1917.
15. Keller, M. B., et al. (1982). Double depression: Superimposition of dysthymia on major depression. American Journal of Psychiatry, 139(4), 438-442.
16. Parker, G., et al. (1996). Defining melancholia: Properties of a refined sign-based measure. British Journal of Psychiatry, 169(4), 397-404.
17. Limosin, F., et al. (2000). Major depression and substance abuse comorbidity. European Psychiatry, 15(3), 129-135.
18. Black, D. W., et al. (1988). Electroconvulsive therapy in Iowa. Convulsive Therapy, 4(4), 253-260.
19. Heijnen, W. T., et al. (2010). Antidepressant and antipsychotic combination therapy in psychotic depression. Journal of Clinical Psychopharmacology, 30(6), 596-602.
20. Coryell, W., et al. (2001). Outcomes of patients with psychotic depression. Archives of General Psychiatry, 58(3), 240-246.
21. Tohen, M., et al. (2003). The bipolar disorder: A comprehensive review. Journal of Affective Disorders, 73(1-2), 3-14.