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Treatment-Resistant Depression — MRCPsych Paper B MCQ

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EasyMood DisordersTreatment-Resistant DepressionMRCPsych Paper B

A 50-year-old woman with moderate depression has had no meaningful response after taking sertraline 200 mg daily for 8 weeks. Adherence is confirmed, the diagnosis has been reviewed, and no comorbid condition or psychosocial factor explaining non-response is identified. She has no psychotic symptoms, is eating and drinking adequately, and presents no immediate risk requiring admission. She wishes to continue with antidepressant monotherapy. According to NICE NG222, which is the most appropriate next management option to discuss?

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Correct answer: E — Switch to mirtazapine or venlafaxine

The correct answer is E. NICE NG222 recommends discussing further-line treatment after confirming adherence, reviewing possible reasons for non-response and allowing an adequate antidepressant trial. If the person wishes to continue antidepressant monotherapy, changing medication is appropriate; this may involve switching within the same class or to another class, such as mirtazapine or an SNRI such as venlafaxine. NICE does not state that switching class is invariably superior to switching within class. ECT is principally considered for severe depression when a rapid response is required, previous ECT is preferred, or other treatments have failed. Repetitive transcranial magnetic stimulation is an available procedure but is not the routine next step after one antidepressant trial. Admission requires clinical need such as significant risk or inability to maintain safety, while psychosurgery is inappropriate.

Reference: National Institute for Health and Care Excellence. Depression in adults: treatment and management (NG222), recommendations 1.9.1–1.9.5 and 1.13.1. 2022; reviewed 2026. https://www.nice.org.uk/guidance/ng222/chapter/recommendations