Patient evaluation on intake

42-year-old man with a chief complaint of depression and family stress

Psychiatric history

Was doing well until he became stressed with household issues and family issues

Remains gainfully employed as an assembly line worker despite his stress

When seen by a previous provider, was diagnosed with minor depression/adjustment disorder and placed on a minimal dose trial of an SSRI

Goes to weekly supportive psychotherapy

His psychiatrist moved and he presented for admission with minor depressive symptoms as noted

However, this initial psychiatric interview revealed poor sleep, irritable and low mood, poor concentration, affect constriction, loss of speech prosody, and concrete thoughts

Furthermore, when asked about psychotic symptoms, the patient nonchalantly stated that he did in fact receive messages from the TV, radio, and the assembly line at work. He admitted to “picking things up” all the time

Outside picking up messages from the TV

• – If a car drove by, he could hear people talking in the car even if they were miles away

• – He would also pick up images in mirrors

• – These took the form of hallucinations with which he has interacted

• – The messages he received from these were mostly neutral and not affective laden, although some are derogatory

• – These have been present for at least a year

• – He is not distressed over these occurrences

Currently takes only an SSRI from the previous provider

• – Sertraline (Zoloft) 50 mg/d

No other previous medication trials

No psychiatric admission history

No suicide attempts

Social and personal history

Married and has four adult children

High school educated and is working full time

Has a supportive wife, but they have had difficulties in the past

Does not drink alcohol, smoke cigarettes, or abuse drugs

There are no legal issues and he gets along well in the community and at work

Medical history

There are no acute and no chronic medical problems

Normal with regard to height, weight, and vitals

There are no abnormal movements

Family history

MDD in mother

SUD throughout extended family

ADHD in grandson

Current psychiatric medications

Sertraline (Zoloft) 50 mg/d (SSRI)

Current medical medications

None

Question

Based on this patient’s history and the available evidence, what do you consider his diagnosis to be?

MDD with psychotic features

Adjustment disorder

Schizophrenia

Schizoaffective disorder

Schizotypal personality

What would your next treatment likely be?

Increase the SSRI, as sometimes this alleviates depressive psychosis

Add an atypical antipsychotic

Switch to an atypical antipsychotic

Better delineate his diagnosis

Refer for CBT or family therapy

Attending physician’s mental notes: initial evaluation

This patient is psychotic, which was apparently missed by the previous providers

He is not guarded. Perhaps this was missed as he appears normal to most people, has a family, is gainfully employed, is older, and does not “look schizophrenic”

Perhaps these symptoms have started in last few months and these did not exist when he started treatment with the prior provider

Perhaps these symptoms have been present for several years regardless of his stress and depression levels and he has learned to live with them

His depression is mild at best and does not appear severe enough to fuel psychotic symptoms

Will need to see if he is psychotic even when fully euthymic, which suggests the differential diagnosis of schizoaffective disorder versus schizophrenia

Will need to rule out substance-induced psychosis, although his history suggests no drug abuse

Will need to rule out medically induced psychosis as he is a bit older with regard to developing schizophrenia