What is the difference between depression and schizophrenia

Depression in schizophrenia: features of the course

The basis of the complex clinical picture of schizophrenia consists of positive and negative symptoms. Positive symptoms include delirium, hallucinations and thought disorders. Negative symptoms are represented by affective changes and are closely related to the development of depression in schizophrenia, which is a frequent and significant sign of the disease.


The frequency of depressive features in schizophrenic disorder is about 40%, but this figure varies with individual circumstances. It increases to 60% during the acute episode and decreases to 20% in the chronic course of the illness and to 50% after the first attack in the post-psychotic episode.

An obvious connection between negative symptoms of the disorder and depression proper has been established. These include the following manifestations:

  • Emotional dullness, absence or reduced intensity of manifested emotional reactions;
  • poor speech;
  • lack of capacity for pleasure;
  • lack of motivation and will.

Depressive changes include:

  • low mood;
  • sleep disturbances;
  • low self-esteem;
  • inability to enjoy oneself;
  • apathy;
  • decreased motor activity;
  • pessimistic thoughts.

Depressive signs are fairly common in schizophrenic disorder and occur in all of its forms. They are second only to hallucinatory, paranoid and apathetic states in prevalence.

Because of the similarity of symptoms, it is sometimes very difficult to distinguish depression from negative symptoms. In addition, depression can provoke the development of secondary negative symptoms, making differentiation even more difficult.

Identifying depressive features in the context of schizophrenic disorder becomes an important point of controlling for it. The point is that depression is a condition at which the risk of suicidal ideation and actual suicide is high. Therefore, the earlier assumption that the predominance of affective symptoms over positive ones in the clinical picture of the disorder is evidence of a more favorable course of the disorder is currently rejected.

Depression in comparison with command hallucinations is much more likely to provoke suicide attempts in schizophrenia. It has been found that the mortality rate of such patients from suicide attempts is greater than in other disorders. It is considered that depressive symptoms in the schizophrenia picture provoke drug and drug addiction and increase the level of life dissatisfaction.

The most common theory of the emergence of depressive states in this disorder is called the personal reaction of patients to it. After experiencing the first episodes of the disease, a person has a feeling of being changed, helplessness, possible loss of professional perspective, friends, and family.

How depression in schizophrenic disorder manifests itself

Depressive manifestations on the background of schizophrenic pathology are very similar to its negative signs. These are, first of all, apathy, absence of vital energy, and also mental anesthesia – a frequent symptom of endogenous depressions. It is called painful insensitivity. At the forefront of the symptom is a loss or reduction in the degree of emotional responses. The patient shows no feelings toward loved ones and others, no emotional response toward any activity, and is incapable of empathy – compassion. Ethical and aesthetic aspects of behavior and perception are also not peculiar to him.

In addition to mental insensibility, the patient feels bodily insensibility. It manifests itself as an absence of various kinds of sensations. At times, a person cannot feel any part of the body.

In addition to those listed, depressive schizophrenic manifestations include other signs. For example, moodiness, dissatisfaction, grumpiness, capriciousness, irritability.

Depression often occurs in the prodromal period, which then passes directly into schizophrenia. In this case, its manifestations are anxiety and irritability, loss of energy, and insomnia. Such symptoms are often confused with banal overexertion.

Elevated tearfulness, sensitivity, irritability, pessimistic mood along with underestimation of self-esteem and “self-digestion” in the prodrome of schizophrenia are perceived as seasonal phenomena.

Depression with signs of rejection is characteristic of both the onset of the disorder and its further development. This condition includes anxiety and symptoms of negative affectivity:

  • anhedonia – inability to enjoy oneself;
  • apathy;
  • indifference;
  • monotonous, restricted movements;
  • cognitive decline;
  • energy deficit;
  • paucity of emotion.

Depressive manifestations in the form of borderline erotomania are characterized by tormenting memories of the object of love. At the same time, in the clinical picture, phenomena of hypotimia, i.e. low mood, are poorly expressed, but external expressive reactions prevail. Therefore such depression is referred to as hysteroid.

The intrusive states of the depressive process in schizophrenia are characterized by heightened anxiety which can develop into a generalized anxiety disorder. The process is joined by hypothymia and a tendency to pathological doubts when the person needs to make a decision, to make a choice.

Depressive episodes can be present not only at the beginning or in the height of the illness, but also as its consequence. Contributing to this is the negative social environment around the person:

  • Poor relationships with relatives, loneliness;
  • labeling;
  • Inability to perform professional or other activities;
  • side effects of medications.

Post-schizophrenic depression is manifested by the standard depressive symptoms. This is a lowered mood, lack of interest in all areas of life, and the constant presence of a feeling of dissatisfaction. Together with this, the patient has mental and physical passivity. Apathy, loss of strength and decreased ability to work are observed. Notes of aggression may be present. Some symptoms of the underlying disorder also persist, but do not come to the foreground.

The post-schizophrenic depressive form develops in a quarter of patients and is characterized by a high risk of suicide.

How to differentiate between schizophrenia and depression

It is very important in the context of schizophrenic disorder to distinguish depression as one of its features. But, given the similarity between depressive symptoms and negative schizophrenic symptomatology, professionals are faced with the problem of how to differentiate between these disorders. We are talking about when a patient has a group of effective changes, but it is difficult to decide on the diagnosis: depression or schizophrenia. The question arises: how are they different?

There are some criteria to help differentiate these concepts. Schizophrenic disorder involves some oddities or illogic behavior. If we trace the period of puberty of the patient, we should note its pathological nature with personality disorders. Schizophrenia is also confirmed by certain psychotic episodes accompanied by fear, anxiety, depersonalization, aloofness.

Example: a young man complains of a lowered mood, insomnia, a sensation of constant anxiety which does not allow him to relax. Every time he falls asleep, he is haunted by the same thoughts: I am a failure, I have not achieved anything in life. The boy became distracted, his attention span was impaired. All the signs of a depressive disorder are there. But from the medical history we know that when he was in school, he paid little attention to the educational process, spending practically all his time on the street.

Subsequently, the man did not learn any profession. He lived for his own pleasure, did not work. Attempts to engage in activity were ultimately abandoned. He got married. But the marriage did not last long: according to the patient, he had to separate with his wife, since her father tried to poison her in order to take over the apartment. The sick man and his mother-in-law defended his wife, but soon the mother-in-law died. Then the guy carried a knife with him everywhere to protect himself and his beloved in case of an attack. But, no longer being able to fight the problem alone, he decided to get a divorce.

The patient himself insists that massage can cure him.

The costs of pharmacotherapy

As a rule, the main drug therapy for schizophrenic disorder is neuroleptics. They help to cope with positive symptoms: eliminate delusions and hallucinations, but in some cases they can cause side effects in the form of neuroleptic depression, characterized by melancholy phenomena with signs of mental anesthesia.

Neuroleptic depression begins with signs of akathisia. They are manifested by an inner feeling of restlessness, anxiety, which varies from mild, barely perceptible, expression to irrepressible anxiety. It feels as if it is eating the patient up from the inside. He cannot sit still and feels the need to constantly change his posture.

Extrapyramidal symptoms in the form of parkinsonism, tremor and hyperkinesias are a peculiarity of the neuroleptic-induced depressive state. Later, signs of psychic anesthesia join. Irritability, sullenness, obnoxiousness increase, and sleep is disturbed.

To reduce the likelihood of such side effects of neuroleptics in schizophrenia, they are prescribed in combination with antidepressants. The latter soften the manifestations of depressive symptoms and compensate for the neuroleptic effect.

Psychotic depression

Depression with psychosis is more common than you might think and can be effectively treated.

Severe depression itself is debilitating and frightening. But in some people it occurs along with psychosis, a transient mental condition characterized by abnormal perceptions that may include delusions and hallucinations. When psychosis accompanies major depressive disorder, it is called psychotic depression or depression with psychosis . It is estimated that 14% to almost 50% of people diagnosed with depression have psychotic depression, and geriatric patients are especially prone to it.

Psychotic depression is taken very seriously by psychiatrists because a person suffering from it is at increased risk for self-harm and suicide. The suicide rate for people with psychotic depression when they are ill and in the acute phase is much higher than for severe depression. It is important to distinguish psychotic depression from psychosis and also from schizophrenia. Psychosis itself is not a disease. It is not a disease in itself, just as a fever, for example, is not a disease. Psychosis is caused by a disturbance in the part of the brain that helps us distinguish between what’s going on inside and what’s going on outside. Psychosis is a common phenomenon. About 3% of the population may experience it at some point. Certain changes in the brain cause a person to see or hear things that are not there. And the longer a person experiences psychosis without receiving treatment, the more they begin to become convinced that the things they see and hear are real.” While psychosis may look like schizophrenia, the difference is that a person with schizophrenia will have delusions and hallucinations whether or not they are depressed.


To be called psychotic depression, major depressive disorder must occur along with delirium and/or hallucinations. Typically, psychotic symptoms have a depressive “theme,” such as delusions of guilt, delusions of sinfulness, delusions of impoverishment, delusions of self-abasement, hypochondriac delusions, or nihilistic delusions .

Typically, a person with psychotic depression exhibits depressed, sad moods, anxiety or agitation, poor concentration, and feelings of lack of self-esteem. For example, a person may say that he is dying of cancer, or that he has lost all his money, or that he has done something wrong, such as not paying his taxes. Interestingly, at first glance, these delusions may turn out to be true. There is something real about them. One of the reasons psychotic depression is not easy to diagnose is that people with psychotic depression are often aware that their thoughts may not be “right,” so they keep them to themselves. Then there are the psychotic traits. The person hears or sees voices and things that are not real, which are hallucinations, and believes things that are not real, which are illusions. Hallucinations are very common and are depressing, nihilistic in nature.

Risk Factors

People are also more likely to develop psychotic depression as they age. Psychotic depression can occur in any age group, but it is not uncommon for those with no prior psychiatric history, so psychotic depression can occur at age 60, 70 or 80. Older people are more likely to have delusions of poverty (impoverishment) or somatic delusions, such as the belief that one is suffering from a terminal illness.

How psychotic depression differs from schizophrenia

If a person has pure psychosis, with no manifestation of depression, it is most likely schizophrenia. And in schizophrenia, depression usually does not predominate, and the person has hallucinations and delusions that don’t go away. They also have decreased thinking, feeling, and motivation. Schizophrenia usually first appears when the patient is in their late teens or early 20s, whereas people can have psychotic depression at any age. Schizophrenia is more prolonged and not episodic.

Treatment for psychotic depression

There are two ways to treat psychotic depression. A combination of an antidepressant and an antipsychotic is the main treatment, and electroconvulsive therapy (ECT) is one treatment option (its use depends on the severity of the condition).

Psychotherapy may also be helpful, but only after the first line of treatment with medication or ECT has begun.

The prognosis for recovery from psychotic depression is very favorable. But for the most part, a person who receives proper treatment for psychotic depression can return to their normal state in a couple of months.

At the first signs of illness, it is important to see a doctor right away . A correctly diagnosed and timely treatment can preserve health and quality of life for years to come.

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