A 45-year-old man is hospitalized due to suicidal ideation. Over the past month, the patient has become increasingly depressed, withdrawn, and physically restless. He has had increasing difficulty concentrating at his job as a computer programmer. The patient's appetite has been poor, and he has had difficulty falling and staying asleep. He stopped going to work last week and refused to leave the house until his hospitalization. The patient has no medical or psychiatric history. Physical examination is unremarkable apart from a 4.5-kg (10-lb) weight loss. On mental status examination, the patient appears depressed and anxious. He reports that he is responsible for "all the evil in the world" and has heard a voice for the past week telling him that he does not deserve to live. Which of the following is the most likely diagnosis in this patient?

Question

A 45-year-old man is hospitalized due to suicidal ideation.  Over the past month, the patient has become increasingly depressed, withdrawn, and physically restless.  He has had increasing difficulty concentrating at his job as a computer programmer.  The patient's appetite has been poor, and he has had difficulty falling and staying asleep.  He stopped going to work last week and refused to leave the house until his hospitalization.  The patient has no medical or psychiatric history.  Physical examination is unremarkable apart from a 4.5-kg (10-lb) weight loss.  On mental status examination, the patient appears depressed and anxious.  He reports that he is responsible for "all the evil in the world" and has heard a voice for the past week telling him that he does not deserve to live.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This patient's presentation is consistent with major depressive disorder (MDD) with psychotic features. This disorder is a severe subtype of MDD in which the patient develops psychotic symptoms exclusively during a depressive episode. This patient's ≥2 weeks of depressed mood, impaired concentration, decreased appetite/weight loss, sleep disturbance, and suicidal ideation meet criteria for MDD, and his psychotic symptoms (eg, delusions of causing evil, auditory hallucinations) specify the psychotic features subtype. Delusions and hallucinations are commonly mood congruent and have depressive themes (eg, deserved punishment, worthlessness, nihilism), although mood-incongruent psychotic symptoms (unrelated to depressive themes) can also occur. Differentiating MDD with psychotic features from MDD without psychotic features is important as treatment differs. Patients with MDD with psychotic features require combined treatment with an antidepressant and antipsychotic or electroconvulsive therapy. (Choice A) This patient has no history of mania or hypomania, thereby ruling out bipolar disorder. (Choice B) In delusional disorder, patients experience delusions but no other psychotic symptoms for at least a month. Mood symptoms, if present, are brief and not a prominent part of the illness. (Choice D) Patients with schizoaffective disorder also experience both mood and psychotic symptoms. Schizoaffective disorder is differentiated from MDD with psychotic features by the presence of delusions and/or hallucinations for ≥2 weeks in the absence of MDD mood symptomatology. There is no evidence that this patient has experienced psychotic symptoms outside of his MDD episode. (Choices E and F) Patients with schizophreniform disorder and schizophrenia experience psychotic symptoms in the absence of an identifiable mood disorder. In schizophreniform disorder, symptoms last ≥1 month but <6 months; in schizophrenia, symptoms persist for ≥6 months. Educational objective: Major depressive disorder (MDD) with psychotic features is a severe subtype of unipolar major depression characterized by symptoms meeting the criteria for MDD and the presence of delusions and/or hallucinations. __________ References: Challenges in the treatment of major depressive disorder with psychotic features. (http://www.ncbi.nlm.nih.gov/pubmed/23599251) Prevalence and clinical characteristics of psychotic versus nonpsychotic major depression in a general psychiatric outpatient clinic. (http://www.ncbi.nlm.nih.gov/pubmed/18781658)

A 45-Year-Old Man Is Hospitalized Due to Suicidal Ideation