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Psychotic Depression — MRCPsych Paper B MCQ

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ModerateMood DisordersPsychotic DepressionMRCPsych Paper B

A 32-year-old woman is admitted with a severe depressive episode and mood-congruent nihilistic delusions that her internal organs have rotted away. She has shown no meaningful improvement after an adequate 6-week trial of combined antidepressant and antipsychotic treatment at therapeutic doses, with adherence confirmed. She is now refusing food and fluids because of her delusional beliefs. Which treatment should now be considered?

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Correct answer: C — Electroconvulsive therapy

Electroconvulsive therapy is the best answer. She has severe psychotic depression that has not improved despite an adequate combined antidepressant–antipsychotic trial, and her refusal of food and fluids creates a need for rapid clinical response. NICE recommends considering ECT for severe depression when other treatments have been unsuccessful or when rapid response is required, such as in life-threatening self-neglect. Lithium augmentation is a recognised further-line strategy but is less appropriate when urgent improvement is required. Switching antipsychotics would delay effective treatment without addressing the immediate risk. Repetitive transcranial magnetic stimulation is not the preferred acute intervention for this severe, psychotic and medically hazardous presentation. Psychodynamic psychotherapy may contribute to longer-term care but is not an adequate acute treatment for psychotic depression with food and fluid refusal.

Reference: National Institute for Health and Care Excellence. Depression in adults: treatment and management (NG222), section 1.13, recommendation 1.13.1. 2022. https://www.nice.org.uk/guidance/ng222/chapter/recommendations