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Psychotic Depression — MRCPsych Paper B MCQ

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ModerateMood DisordersPsychotic DepressionMRCPsych Paper B

A 45-year-old woman has experienced pervasive low mood, loss of interest, marked psychomotor retardation, significant weight loss, early-morning waking and diurnal mood variation for 6 weeks. She has active suicidal ideation with a plan and is unshakeably convinced that her internal organs have rotted away, despite reassurance and a normal physical examination. Her PHQ-9 score is 27. There is no history of mania or hypomania. Which classification best describes the current episode?

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Correct answer: E — Severe depressive episode with psychotic symptoms

The best answer is E. She has a severe depressive syndrome, indicated by pervasive biological symptoms, marked psychomotor retardation, substantial functional impairment and active suicidal intent. Her fixed belief that her organs have rotted away is a mood-congruent nihilistic delusion and therefore a psychotic symptom. The PHQ-9 score supports high severity but should not replace comprehensive clinical assessment. Mild, moderate and subthreshold categories cannot account for this combination of severity and psychosis. Bipolar depression requires a history of mania or hypomania, which is explicitly absent. NICE recommends specialist mental health assessment and says to consider combined antidepressant and antipsychotic treatment; such combination treatment is not invariably required. ECT is considered when a rapid response is needed, previous ECT is preferred based on benefit, or other treatments have been unsuccessful—not automatically solely because suicidal ideation is present.

Reference: NHS, ICD-10 5th Edition, Chapter V, F32.3 Severe depressive episode with psychotic symptoms. https://classbrowser.nhs.uk/ICD-10-5TH-Edition/vol1/block-f30-f39.htm