“My Patient is Hearing Voices. What do I do?” 3/7/2019

Case Study: Patient Presenting with Mood and Psychotic Symptoms

This article is based on a recent SmartCare consultation with a primary care provider.

Case: 36 yo male who is a new patient presents with depressive symptoms since age 14 and previous suicide attempt at age 18. Additionally, he reports voices telling him negative things about himself and telling him to kill himself. He denies current suicidal ideation (SI). He is currently taking fluoxetine (Prozac) 20mg with moderate effect on his depression symptoms, but with no improvement in his hallucinations.

While ideally a patient like this would be seen by a psychiatrist, these patients often present in the primary care world because of limited access to psychiatry. It is therefore useful for primary care clinicians to have a basic understanding of how to tease apart the above clinical presentation, key follow up questions to ask, and next steps in terms of treatment recommendations.

Given the above clinical information, the patient is presenting with depressive symptoms and psychotic symptoms. To distinguish between true auditory hallucinations versus negative thoughts related to depression, one could ask “Are the voices inside your head or outside of your head?” If the patient reports that they are inside his head, then they are not likely to be true auditory hallucinations, but rather a manifestation of his depression. If the symptoms are concerning for true auditory hallucinations (“outside his head”), it would be important to ask about other psychotic symptoms including visual hallucinations, delusions and disorganized thinking and behavior. It would be important to also ask about drug and alcohol use. Given the report of depressive symptoms, it would also be important to ask about a history of manic or hypomanic symptoms.

If the patient endorses both depressive symptoms and psychotic symptoms, it would be important to find out if they always occur together or if there are times he has depressive symptoms without psychotic symptoms and/or psychotic symptoms without depressive symptoms. This is important to help determine an accurate diagnosis, whether the primary disorder is a mood disorder or a psychotic disorder. This impacts prognosis with mood disorders generally having better prognoses than psychotic disorders. Asking about level of functioning with respect to education and occupation, as well as relationships, can be helpful to determine if the clinician should be concerned about a primary psychotic disorder.

For the above case, the differential boils down to major depressive disorder (MDD) with psychotic features versus schizoaffective disorder (SAD) depressive type. The former has a better prognosis than the latter. If the patient only reports psychotic symptoms when he is severely depressed then the likely diagnosis is MDD with psychotic features. If he reports the psychotic symptoms occur even when his mood is stable and his mental health symptoms have caused him to not be able to maintain a job or a relationship, then there is more concern for SAD depressed type.

When considering treatment, if the psychotic symptoms occur in the context of a severe depression, it is important to begin treatment with an antidepressant and therapy. Short- term low dose antipsychotic medication could be considered to help with the psychotic symptoms as well as augmentation for the severe depression. If there is a concern for SAD depressive type, then the mainstay of treatment would be an antipsychotic medication with additional antidepressant as needed when the patient is experiencing a depressive episode.

Case Discussion: When obtaining additional history, the patient reports that the voices that he hears are outside his head and denies other psychotic symptoms. He reports the hallucinations only occur when he is very depressed although this time he reports his depression has improved but the hallucinations have not reduced in frequency. He reports that in the past olanzapine (Zyprexa) was helpful for the hallucinations.

Treatment Recommendations: Given that the patient’s depression was fairly well controlled with the fluoxetine, recommended continuing at the current dose. The dose can be increased over time, if needed, if the depression worsened. If the depression was not well controlled would have recommended increasing the dose.

For the hallucinations, it was recommended to add low dose aripriprazole (Abilify) 1-2mg qday (keeping in mind the drug interaction between fluoxetine and aripriprazole) on a temporary basis. It was also recommended that the patient engage in therapy and be referred to psychiatry for long term management, if possible.

It is our hope that this extensive discussion about a real consultation was helpful for primary care providers who might see patients with similar presentations. SmartCare is available to help guide these challenging clinical cases (858-880-6405).

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