Case 24: An accountant who expects to be put on trial for her mistakes

Case 24: An accountant who expects to be put on trial for her mistakes

A 30-year-old accountant, low for a month and waking early, who is sure she will be put on trial for mistakes her colleagues say she never made.

  • 2 min read
  • Checked 01 Nov 2026

The case

For the past month a 30-year-old woman has felt very low. She cries often, wakes early in the morning and, constantly tired, has let her housework go. She keeps telling her husband that she must give up her job because of mistakes she made in the accounts, and that she will probably be put on trial for them. Her colleagues say there were no such mistakes. Lately she has said she would be better off dead, so that her family would be spared the shame.

Summary

Diagnosis

A severe depressive episode with psychotic symptoms (psychotic depression), with delusions of guilt.

What points to it

  • Markedly low mood, crying, early morning waking.
  • Lack of energy and initiative, and neglect of everyday tasks.
  • Delusions of guilt and of coming punishment, held against the evidence of her colleagues. They fit her mood (mood-congruent), which marks the depression as psychotic.
  • The wish to be dead to spare her family shame.

What else it could be

A first depressive episode in a young adult may be the start of bipolar disorder, more often when it is psychotic, so ask about past highs and a family history. Schizoaffective disorder if the delusions persist once the mood has lifted.

Management

  • The suicide risk is high: depression, psychotic guilt and a stated wish to die, with a motive (sparing her family) that makes sense to her. Ask about plans and means, and admit her.
  • An antidepressant together with an antipsychotic.
  • ECT, which works fast and well in psychotic depression: a first choice when the suicide risk is acute or she stops eating and drinking, and the next step if drugs fail.
  • Involve her husband: watch for warning signs, and keep her environment safe.
  • Continue treatment for months after recovery, and plan relapse prevention.

Outlook

Good for the present episode, but the risk of further episodes over the years is high, and some will be manic. Relapse prevention has to allow for that: an antidepressant alone may tip a person with bipolar disorder into mania.