The underreporting of psychotic symptoms by patients in depression is a significant concern, frequently driven by the fear of consequences like hospitalization or the stigma of embarrassment.    We'll discuss the history, the differential to consider when thinking of psychotic depression, mechanisms, and treatment. Notably, individuals with psychotic depression face a suicide rate double that of their non-psychotic counterparts. A recent cohort study by Paljärvi in 2023 revealed a stark contrast: deaths due to suicide were 2.6% in the psychotic depression cohort, compared to 1% in the non-psychotic group. Alarmingly, most suicides occurred within the first two years following diagnosis. People who suffer from psychotic depression often do not report their psychotic symptoms, leading to inadequate response to normal depression treatments. With 6-25% of individuals with major depressive disorder (MDD) exhibiting psychotic features, it is imperative to understand and address these unique challenges. Join us as we unravel the complexities of this underrecognized aspect of mental health.