The prevalence in the community of psychotic (delusional) major depression (PMD) in the elderly was found to be 1%. In inpatient settings the frequency of the disorder varies between 24% and 53%. There is also evidence that its frequency increases in old age. In the elderly, PMD compared to non-PMD was found to be a more severe and melancholic form of depression with more psychomotor disturbances (agitation or retardation) and feelings of guilt, more anxiety and hypochondriacal complains and less insight. Delusional beliefs of paranoid and hypochondriacal content have been found to be prominent. Additionally, elderly psychotic depressives (PDs) are possibly at greater risk of suicide attempt. Also, elderly PDs have been observed to have more cognitive processing difficulties. As regards neurobiological findings, they have been found to have lower dopamine-beta-hydroxylase activity, smaller volume of prefrontal cortex, more brain stem and left-side frontotemporal atrophy, enlargement of the third ventricle and pontine reticular formation hypertensities. The prognosis for the disorder seems worse, with higher relapse rates and mortality although not all studies are in agreement. In the acute phase, the response to ECT is favourable (88%), however the response rates to combination of an antipsychotic and an antidepressant (25-50%) seem to be inferior to those observed in younger adults (70-80%). Close follow-up and continuation therapy with an antidepressant is needed to avoid relapses.