The therapeutic strategies in managing patients with psychotic major depression (PMD) differ from those with non-psychotic major depression (NMD), because of differences in clinical profile and outcome. However, there is underrecognition of psychotic symptoms in depressed patients. Previous studies in Western population suggest that certain symptom patterns, apart from psychosis which may be concealed, can facilitate the discrimination of PMD from NMD. These studies may have limited applicability to sub-Saharan Africa due to cross-cultural differences in the phenomenology of depression. This study compared the rates and severity of depressive symptoms in outpatients with PMD ( ) and NMD ( ) using the Structured Clinical Interview for Depression (SCID) and Hamilton Depression Rating Scale (HAM-D). Patients with PMD had statistically significantly higher rates of suicidal ideation, suicidal attempt, psychomotor agitation, insomnia, and reduced appetite. Patients with NMD were more likely to manifest psychomotor retardation and somatic symptoms. PMD was associated with greater symptom severity. On logistic regression analysis, suicidal ideation, psychomotor disturbances, insomnia, and somatic symptoms were predictive of diagnostic status. The presence of these symptoms clusters may increase the suspicion of occult psychosis in patients with depression, thereby informing appropriate intervention strategies. 1. Introduction Depression is a common psychiatric disorder estimated to affect about 1 out of 5 people in their lifetime [1]. It is a leading cause of disability, projected to become the second leading contributor to the global burden of disease by the year 2020 [2]. Clinically, a major depressive episode or disorder is characterised by the presence of depressed mood, loss of interest, low energy, and significant changes in sleep, appetite, weight, and psychomotor activity. Other symptoms include indecisiveness, feelings of worthlessness, guilt, and suicidality [3, 4]. Epidemiological evidence indicates that about 19 to 25% of patients with major depression have psychotic symptoms, typically delusions and hallucinations [5]. In comparison to Nonpsychotic major depression (NMD), patients with psychotic major depression (PMD) have a worse clinical course characterised by higher rates of recurrence, treatment resistance, suicidality, psychosocial impairment, overall symptom severity, and comorbidity [6–9]. Research has shown that there is underdetection of psychotic symptoms in depressed patients because psychotic symptoms may be subtle, intermittent,
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