Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Major Depressive Disorder, Severe, with Psychotic Features


Related Terms

  • Depressive Psychosis
  • Major Depressive Episode with Psychotic Features
  • Psychotic Reactive Depression
  • Severe Depression with Psychotic Features

Differential Diagnosis

  • Bipolar disorder
  • Dementia
  • Hypothyroidism
  • Mood disorder due to a general medical condition
  • Other psychotic disorders
  • Psychotic disorder due to a general medical condition
  • Schizoaffective disorder
  • Substance-induced mood disorder
  • Substance-induced psychotic disorder

Specialists

  • Psychiatrist

Comorbid Conditions

Factors Influencing Duration

The length of disability is influenced by the duration and severity of the depressive episode and psychotic features, any underlying mental illness, any substance abuse, the individual's social support system, the appropriateness of the treatment choice, the individual's compliance with treatment and response to medications, and the adequacy of ongoing care.

Medical Codes

ICD-9-CM:
296.24 - Major Depressive Disorder, Single Episode; Severe, Specified as with Psychotic Behavior
296.34 - Major Depressive Disorder, Recurrent Episode; Severe, Specified as with Psychotic Behavior
298.0 - Depressive Type Psychosis; Psychogenic Depressive Psychosis; Psychotic Reactive Depression; Reactive Depressive Psychosis

Overview

Major depressive disorder, severe, with psychotic features is referred to in ICD-10 as a severe depressive episode with psychotic symptoms ("ICD-10 Version:2015"). This disorder includes symptoms of both a major depressive episode and psychosis in an individual without an underlying diagnosis of a psychotic disorder. A major depressive episode occurs when there is a period of at least 2 weeks during which an individual exhibits depressed mood; a loss of interest or pleasure in nearly all activities; and at least three other symptoms, including significant and unintended weight gain or loss, insomnia or sleeping excessively (hypersomnia), psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or inappropriate guilt, lack of concentration, and recurrent thoughts of death or suicidal ideation. The presence of one or more major depressive episodes is a criterion for the diagnosis of major depressive disorder.

In a major depressive disorder with psychotic features, the individual reports or exhibits false, persistent beliefs (delusions) and/or hears or sees things that aren't there (hallucinations, usually auditory but sometimes visual). The delusions or hallucinations usually refer to depressive themes (mood-congruent psychotic features), such as the belief that one is responsible for the death of a loved one or that one is being punished because of a moral transgression. Hallucinations are usually temporary and may involve voices that berate the individual for perceived wrongs. Occasionally, the content of the delusions or hallucinations has no apparent relationship to depressive themes (mood-incongruent psychotic features) and may include delusions that one is being persecuted or that others can control one's thoughts. In general, mood-incongruent psychotic features are associated with a poorer prognosis than mood-congruent psychotic features.

It is not known why some individuals with a major depressive disorder develop psychotic features, but it is most likely related to disturbances in brain chemistry (dysregulation of neurotransmitter systems). Involved brain chemicals may include serotonin, dopamine, norepinephrine, acetylcholine, and gamma-aminobutyric acid, as well as other hormones and enzyme systems. Psychotic symptoms are most likely to emerge in the 3-month period following any major life event, such as bereavement or job loss.

Culture can influence the way in which an individual experiences and expresses a major depressive episode. Somatic complaints of nervousness or headaches in Latino cultures, weakness or imbalance in Asian cultures, heart problems in Middle Eastern cultures, or feelings of sadness and guilt in North American and Western European cultures may all be expressions of depression that combine features of depressive, anxiety, and somatoform disorders. An individual's culturally guided fear of being bewitched or feeling of being visited by the dead must be distinguished from actual hallucinations or delusions.

Incidence and Prevalence: In the US, 6.7% of adults will develop major depressive disorder in a given year (NIMH).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Women are 70% more likely than men to develop a major depressive disorder in their lifetimes, and non-Hispanic blacks are 40% less prone to depression than non-Hispanic whites (NIMH). Major depressive disorder is 1.5 to 3 times as frequent in individuals who have a first-degree biological relative diagnosed with the disorder (DSM-IV-TR).

Source: Medical Disability Advisor



Diagnosis

History: According to the DSM-IV-TR, major depressive disorder, severe, with psychotic features, involves the presence of either delusions or hallucinations (typically auditory) during the current episode. The delusions or hallucinations almost always are consistent with the depressive themes. Such mood-congruent psychotic features comprise delusions of guilt, delusions of deserved punishment, nihilistic delusions (the belief that the individual, a part of individual's body, or the real world doesn't exist or has been destroyed), somatic delusions (the belief that the individual's bodily functioning, sensation, or appearance is abnormal, diseased, or changed), or delusions of poverty. When hallucinations are present, they are almost always transient and not elaborate and may involve voices that scold the individual for shortcomings or sins (DSM-IV-TR).

In a few individuals, the hallucinations or delusions have no relationship to depressive themes. Such mood-incongruent psychotic features comprise persecutory delusions, delusions of thought insertion (the belief that individual's thoughts are not the individual's own), delusions of thought broadcasting (the belief that other persons can hear the individual's thoughts), and delusions of control (the belief that individual's actions are under external control). The presence of these features is associated with a poorer prognosis (DSM-IV-TR).

According to the DSM-5, in order to make the diagnosis of major depressive disorder, 5 of a total of 9 symptoms must have been present during the same 2-week period and represent a change from prior functioning. If only 5 of the 9 symptoms are present, generally the specifier applied is "mild." Labeling depressive disorders as "severe" indicates that most of the 9 symptoms are present, including motor agitation. "With psychotic features" indicates the presence of delusions and/or hallucinations; this specifier may be "with mood-congruent psychotic features," when all delusions and hallucinations are consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment; otherwise this specifier may be "with mood-incongruent psychotic features," when the delusions or hallucinations do not involve such typical depressive themes, or the content is a mixture of mood-incongruent and mood-congruent themes (DSM-5).

The individual, family members, and/or friends usually give a history of several weeks to months of depressed mood, feelings of sadness or hopelessness, poor appetite or overeating, difficulty sleeping (insomnia) or sleeping too much (hypersomnia), low energy and fatigue, low self-esteem, poor concentration, difficulty making decisions, thoughts of death, or a suicide attempt. The individual may also give a history of problems at work, relationship and/or sexual problems, having the same unpleasant or worrisome thoughts over and over (obsessive rumination), anxiety, excessive worry over physical health, multiple somatic complaints (indigestion, headaches, fatigue, stomach pain, back pain), or alcohol/substance abuse.

Physical exam: The individual may be tearful or have a facial expression that is sad or lacking in animation. There may be restlessness and hyperactivity (psychomotor agitation) or slowed, decreased movement (psychomotor retardation), documented unintended weight gain or loss, and wrist lacerations or other evidence of recent suicide attempts.

Tests: There are no diagnostic laboratory tests for this disorder, but the electroencephalogram (EEG) may indicate sleep abnormalities. The Beck Depression Inventory (BDI) is a brief self-rating scale useful in monitoring changes in level of depression with treatment. The Minnesota Multiphasic Personality Inventory 2 (MMPI-2) is a more extensive psychological profile that can provide information about the individual's mental and emotional status. There are a variety of other tests that can be administered as well. However, acutely psychotic patients may not be able to attend to the task long enough to make testing useful. Blood work should be done to rule out treatable causes of depression, such as hypothyroidism.

Note: It must be kept in mind that just because a physical diagnosis cannot be established as the cause of the presenting symptomatology, it does not necessarily mean that the cause is a mental one. That is to say that the presence of medically unexplained symptomatology does not necessarily establish the presence of a psychiatric condition. The first step in identifying the presence of a mental disorder is excluding the presence of malingering and/or of factitious disorder. Although factitious disorder is conscious and purposeful, it is classified as a psychiatric disorder. The strong need for this step is especially true whenever there is a medicolegal context associated with the presenting problem(s). Additionally, using DSM-5 and/or ICD-9-CM or ICD-10-CM, the clinician will find that many presentations fail to fit completely within the boundaries of a single mental disorder. There are systematic ways to go about making psychiatric diagnoses, however.

Source: Medical Disability Advisor



Treatment

The goal of treatment is to improve the individual's mood, diminish negative symptoms (anxiety, fatigue, insomnia or hypersomnia, lack of appetite, tearfulness, rumination, suicidal ideation), and diminish or eliminate the psychotic features (delusions and hallucinations) of the depressive episode. Hospitalization may be needed if the physician or mental health professional believes that the individual is dangerous to self or others.

The first line of treatment is the use of antipsychotic and antidepressant medication. Antipsychotic drugs can be effective in reducing or eliminating symptoms such as delusions, hallucinations, and disorganized thinking. Selective serotonin reuptake inhibitor (SSRI) antidepressants and the newer atypical antipsychotics are the medications of choice because of their effectiveness and low level of side effects. For example, a common regimen combines the atypical (second-generation) antipsychotic olanzapine, and the selective serotonin reuptake inhibitor (SSRI) antidepressant fluoxetine.

After the acute symptoms have cleared, the continued use of antipsychotic drugs substantially reduces the probability of future episodes, if the individual does not develop significant adverse effects such as sedation, muscle stiffness, tremors, weight gain, or abnormal muscle movements (tardive dyskinesia). Informed medical monitoring must be a mandatory part of all treatment. Most side effects can be eliminated or minimized by adjustment in dosage or type of medication. Psychotic symptoms should clear up within a few days or weeks of treatment, but depressive symptoms may take 3 to 12 weeks to diminish. Somatic symptoms, such as sleep, appetite, and psychomotor disturbances, usually respond first to medication; and then the cognitive symptoms, such as low self-esteem, poor attention and concentration, guilt, pessimism, or suicidal ideation, diminish.

For proper diagnosis and administration of antidepressant and antipsychotic medication, physicians who are expert in diagnosis and in psychopharmacotherapy must be consulted. It may be necessary to try more than one medication or a combination of medicines to achieve a good result. Because responses differ, several trials of medicine may be needed before an effective treatment is found.

For individuals whose depression is incapacitating, severe, or life-threatening or for those who cannot take or do not respond to antidepressant medications, electroconvulsive therapy (ECT) is a safe and often effective treatment for severe depression. Some newer treatments are on the horizon, but not yet approved.

Biological treatments are the interventions of choice during the acute phase of the disorder. Once the symptoms of severe depression with psychosis are brought under control with medication, then psychotherapy may be added in treating the depressive disorder. Supportive psychotherapy generally provides a therapeutic explanation of the depressive symptoms, includes education and feedback about the progression of the depression, and may include identification of stressors and training in stress management skills. As an empirically based approach, cognitive behavioral therapy has continued to gain in popularity because it is often effective. The goals of therapy may include simple emotional support; insight into sources of thoughts, feelings, perceptions, or behaviors; relief of symptoms such as anxiety or depression; stress management; behavioral changes; or crisis planning. These interventions are designed to help modify the individual's thinking, expectations, and behaviors and improve the individual’s ability to cope with various life stressors.

Source: Medical Disability Advisor



Prognosis

An untreated episode may last 4 months or longer, with remission occurring in 20% to 30% of cases. Some individuals may have symptoms that persist for years and may develop some disability due to these symptoms. About 60% of individuals who have one episode go on to have a second episode, and 90% of individuals who have had a third episode will develop a fourth (Kupfer).

Those who receive treatment have significantly improved recovery rates. Individuals who receive treatment can generally expect a decrease in psychotic symptoms within a few days and improved mood within 2 to 4 weeks. Most individuals are able to return to premorbid functioning, but some will have persistent low-level symptoms. Only 5% to 10% of individuals meet the full criteria for depressive disorder for 2 or more years (Andrews).

Major depressive episode, severe, with psychotic features is a strong risk factor for suicide. In severe, untreated depression, the statistics vary, and underreporting may skew the statistics, but the consensus remains that severe depression with psychotic features puts individuals at risk of suicide.

Source: Medical Disability Advisor



Complications

The most serious complication of major depressive episode, severe, with psychotic features is death from suicide. Individuals with general medical conditions, such as diabetes, carcinoma, stroke, or myocardial infarction, may have a concurrent episode of depression, which complicates the length and treatment of both conditions. Those individuals who are severely depressed or whose psychosis prevents them from getting adequate food or sleep may suffer the physical consequences of malnutrition or other health problems.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Temporary work accommodations may include reducing or eliminating activities in which the safety of self or others is contingent upon a constant and/or high level of alertness, such as driving motor vehicles, operating complex machinery, or handling dangerous chemicals; introducing the individual to new or stressful situations gradually under individually appropriate supervision; allowing some flexibility in scheduling to attend therapy appointments (which normally should occur during the employee's personal time); promoting planned, proactive management of identified problem areas; and offering timely feedback on job performance issues. It will be helpful if accommodations are documented in a written plan designed to promote timely and safe transition back to full work productivity.

Risk: Individuals with depressive psychosis may be at greater risk of harming themselves and/or coworkers during the acute phase of the disorder when delusions or hallucinations are present, if the individuals are suicidal, and/or if the individuals have resorted to alcohol or substance abuse in an attempt to self-medicate their symptoms.

Capacity: Capacity varies according to the individual’s motivation, alertness, and ability to concentrate and focus, which may be impaired by medication and/or symptoms such as sleep deprivation. These factors, in turn depend to some extent on the severity of psychotic and somatic symptoms. Work tasks that are familiar, simple, and not safety-sensitive may be appropriate.

Tolerance: Tolerance depends on the individual’s willingness to acknowledge and deal with his or her symptoms, as well as the individual’s response to treatment. In many cases, involvement with work activities aids recovery once the acute symptoms have cleared.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 12 months of treatment or less.

Note: MMI is estimated under the assumption that the vagaries involved in psychiatric diagnoses have been taken into consideration.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was diagnosis of major depressive episode, severe, with psychotic features confirmed through history and mental status examination?
  • Is the physician trained in psychiatric diagnosis?
  • Was substance abuse identified or ruled out?
  • Has physical exam or testing excluded hypothyroidism, multiple sclerosis, cancer, stroke, or other chronic medical illness?

Regarding treatment:

  • If substance abuse was present, is it being addressed appropriately?
  • Since depressive psychosis indicates that individual is no longer capable of discriminating fantasy from reality, does individual pose a threat to self or others?
  • If delusions and/or hallucinations are present, has physician assessed the degree of danger posed by the delusions and/or hallucinations, particularly the extent to which individual is willing to act on delusions and/or hallucinations? Was individual assessed for violent tendencies?
  • Because a suicide plan represents an emergency situation, was individual assessed for suicidal intent or attempt? Are proper precautions in place to prevent suicide attempt?
  • Is current drug therapy appropriate for individual? Is the dosage high enough to be effective?
  • Is the treating physician adequately trained in psychopharmacology?
  • Was an expert in diagnosis and biochemical therapy consulted?
  • Has individual experienced a positive response from current antidepressant and/or antipsychotic medication(s)?
  • Since individual responses differ, were trials of several medicines or a combination of medicines done to find the most effective treatment? Is a change of medication or dosage warranted at this time?
  • Although antipsychotic drugs may have substantially reduced the probability of future episodes, has individual experienced significant adverse side effects?
  • Since most side effects can be eliminated or minimized by adjustment in dosage or type of medication, is individual competent and diligent in reporting side effects to the doctor? If not, is there a family member or caregiver who could reliably report side effects?
  • Should antipsychotic medications be adjusted, changed, or discontinued? Are additional medications needed to counteract the side effects?
  • If depression is incapacitating, severe, or life-threatening or if individual cannot take or does not respond to antidepressant medications, was electroconvulsive therapy (ECT) considered an option at this time?
  • Was psychotherapy used to help individual recognize and change behaviors, thoughts, or relationships that cause or maintain depression?

Regarding prognosis:

  • Do symptoms persist despite treatment?
  • Does individual have a coexisting condition, such as diabetes, carcinoma, stroke, myocardial infarction, major depression, schizophrenia, anxiety disorders, panic disorder, or bipolar disorder that could complicate treatment or affect recovery?
  • Since it is estimated that only one-third of those diagnosed with depression get proper treatment, is physician a specialist in psychiatric disorders?
  • Would individual benefit from a second opinion?

Source: Medical Disability Advisor



References

Cited

"Depression." National Institute of Mental Health (NIMH). National Institutes of Health (NIH). 22 Apr. 2015 <http://www.nimh.nih.gov/health/topics/depression/index.shtml>.

"ICD-10 Version:2015." WHO. World Health Organization. 22 Apr. 2015 <http://apps.who.int/classifications/icd10/browse/2015/en>.

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association, 2013.

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Andrews, Gavin, et al. "Dimensionality and the Category of Major Depressive Episode." International Journal of Methods in Psychiatric Research 16(S1) (2007): S41-S51.

Kupfer, D. J. "Long-term Treatment of Depression." Journal of clinical Psychiatry 52 (1991): Supp.28-Supp.34.

Source: Medical Disability Advisor






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