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.

Depressive Psychosis


Related Terms

  • 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:
298.0 - Depressive Type Psychosis; Psychogenic Depressive Psychosis; Psychotic Reactive Depression; Reactive Depressive Psychosis

Overview

Depressive psychosis is an older term for what is now referred to in DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision) as a "major depressive episode, severe, with psychotic features," and in ICD-10 as a "severe depressive episode with psychotic symptoms." This disorder includes symptoms of both depression 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 there is either depressed mood; a loss of interest or pleasure in nearly all activities; and at least three other symptoms, including significant, 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; or recurrent thoughts of death or suicidal ideation. The presence of a major depressive episode is a required criterion for the diagnosis of major depressive disorder.

In a major depressive episode with psychotic features, the individual reports or exhibits false beliefs (delusions) and / or hears or sees things that aren't there (usually auditory but sometimes visual hallucinations). 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 major depressive episodes 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 depressive psychosis. 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: Approximately 10% to 25% of women and 5% to 12% of men are at a lifetime risk for developing a major depressive disorder, with only a small percentage of those exhibiting psychotic features.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Women are twice as likely as men to develop a major depressive disorder and, in many cultures, are more encouraged to express their fears and feelings than are men. 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 372).

Source: Medical Disability Advisor



Diagnosis

History: The individual and / or family/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, wrist lacerations or other evidence of recent suicide attempts, listening or talking to people who are not there (hallucinations) or false, persistent beliefs (delusions).

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. 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.

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. For proper diagnosis and administration of antidepressant medication, physicians who are expert in diagnosis and in psychopharmacotherapy must be consulted. Antipsychotic drugs can be effective in reducing or eliminating symptoms such as false beliefs (delusions), hearing or seeing things that aren't there (hallucinations), and disorganized thinking.

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. Selective serotonin reuptake inhibitor (SSRI) antidepressants and the newer atypical antidepressants are the medications of choice because of their effectiveness and low level of side effects. 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. 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.

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(s), 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. 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, expectancies, and behaviors and to increase coping skills for 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.

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 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 two or more years.

Depressive psychosis is a strong risk factor for suicide. In severe, untreated depression, the suicide rate is as high as 15%. Only about one-third of those diagnosed with depression get proper treatment, and about two-thirds of those with any kind of affective disorder are misdiagnosed.

Source: Medical Disability Advisor



Complications

The most serious complication of depressive psychosis is death from suicide. Up to 15% of individuals with major depressive disorder commit suicide, and the risk increases if the individual has an episode of major depression with psychotic features. Up to 25% of 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 where 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.

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 depressive psychosis 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?
  • Was individual assessed for violent tendencies? Because violence may be used in retaliation for imagined persecution, has physician assessed the degree of danger posed by the delusions, particularly the extent to which individuals is willing to act on delusions?
  • If delusions are present, are they leading to a risky situation? Is physician aware of this progression?
  • 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, bipolar depression, depressive-mania, or pure-mania, 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

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

Source: Medical Disability Advisor






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