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Depression in Older Adults — MRCPsych Paper B MCQ

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ModerateOld Age PsychiatryDepression in Older AdultsMRCPsych Paper B

A 74-year-old man has had persistent low mood, anhedonia, reduced energy and impaired functioning for 6 weeks. Clinical assessment confirms a depressive episode, and his PHQ-9 score is 18. He also has mild cognitive impairment but no history of mania or psychosis. He takes no regular medication and has no physical comorbidity indicating a particular antidepressant. After discussion of psychological and pharmacological treatments, he prefers antidepressant medication. Which option best reflects the antidepressant class that NICE advises should generally be considered first choice for most people?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Sertraline, a selective serotonin reuptake inhibitor

Explanation lettering: E = shown as A · D = shown as B · B = shown as C · A = shown as D · C = shown as E

A is correct. NICE does not designate one antidepressant specifically for all older adults. When antidepressant medication is selected, SSRIs are generally well tolerated, have a good safety profile and should be considered first choice for most people; sertraline is an appropriate representative. In older people, the individual drug choice must also account for physical health, interactions, falls, fractures and hyponatraemia. Mirtazapine may be selected for particular clinical features or interaction concerns, but none is given here. Venlafaxine is not the usual initial choice when a suitable SSRI is available. Amitriptyline and lofepramine are TCAs and are not routinely preferred over SSRIs; amitriptyline has marked anticholinergic and cardiac effects, which are particularly undesirable with cognitive impairment. Lofepramine is less toxic in overdose than other TCAs but remains a TCA rather than the general first choice.

Reference: National Institute for Health and Care Excellence. Depression in adults: treatment and management (NG222), antidepressant medication tables and recommendation 1.4.24, 2022, subsequently amended. https://www.nice.org.uk/guidance/ng222/chapter/Recommendations