New Clinical Case Posted: The Weight of Delusional Guilt
UPDATE FOR ACADEMY MEMBERS:
We are excited to share that Clinical Case #7 is now available inside the Academy:
This case presents a powerful and clinically relevant scenario that many psychiatrists encounter in real-world practice—severe depression with psychotic features and treatment resistance.
THE WEIGHT OF DELUSIONAL GUILT
Setting: Outpatient Consultation
Patient: Mr. J, a 52-year-old former accountant.
The Clinical Picture
Mr. J presents with depressed mood, anhedonia, looking disheveled, with marked psychomotor retardation; he speaks in a whisper and takes nearly 10 seconds to respond to simple questions. He is convinced that he has “bankrupted his lineage,” despite his wife providing bank statements showing a healthy 401(k). He views his recent job loss not as a result of his illness, but as “divine justice.”
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Vitals/Physical: Weight loss of 15 lbs in 2 months. Skin turgor is poor.
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Safety: Admits to passive suicidal ideation: “It would be better if I weren’t a burden on the world’s resources.”
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PHQ-9 Score: 21 (Severe).
The “Treatment Failure” Timeline
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Trial 1: Escitalopram 20mg (10 weeks) — No change.
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Trial 2: Venlafaxine XR 225mg (8 weeks) — Persistent mood symptoms + emerging psychosis.
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Trial 3 (Current): Venlafaxine XR 225mg + Risperidone 2mg (6 weeks) — The psychosis is fixed/entrenched; he remains severely depressed.
Medical History: hypertension (controlled on lisinopril 10 mg daily) and hyperlipidemia.
He denies prior manic episodes or substance use.
His family is concerned about his declining function and recent job loss.
What will be your next step in management?
New Academy Learning Format for Clinical Cases:
Moving forward, we are introducing a new interactive clinical learning series:
How it works
A new clinical case will be posted in the Academy forums.
Members can review, reflect, and share their management approach.
After discussion, we will release a downloadable PDF answer sheet that includes:
Evidence-based management
Key clinical pearls
Important guideline references
Practical real-world decision points
👉 This is the first case in this new series, and we are excited to build this into a powerful learning experience for busy clinicians.
We’d Love Your Feedback
Please explore Clinical Case #7 and share your thoughts in the forum.
Do you find this interactive case-based learning format helpful?
Your feedback will help shape future Academy content.
We continue to review and summarize clinically relevant research to support your daily practice.
INTERESTED IN ACCESS TO THIS & OTHER CLINICALLY RELEVANT LECTURE SERIES?
JOIN ACADEMY MEMBERSHIP:
This is a closed membership for medical professionals only.
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- Goal: is to have all important clinically relevant topics in one place for ease of access.
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