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Treatment-Resistant Depression — MRCPsych Paper B MCQ

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ModerateMood DisordersTreatment-Resistant DepressionMRCPsych Paper B

A 45-year-old man remains in a severe depressive episode despite three adequate antidepressant trials at therapeutic doses and durations, followed by specialist lithium augmentation. Adherence and the diagnosis have been reviewed, and no remediable comorbidity has been identified. He has declined CBT. According to NICE NG222, which treatment should specifically be considered because other treatments have been unsuccessful?

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Correct answer: E — Electroconvulsive therapy

The correct answer is E, electroconvulsive therapy. NICE NG222 recommends considering ECT for severe depression when other treatments have been unsuccessful, as in this adequately characterised further-line treatment failure. ECT requires an informed, shared decision that addresses anaesthetic and cognitive risks. rTMS is the strongest distractor: separate NICE HealthTech guidance permits its use because short-term efficacy evidence is adequate, although response is variable, but it is not the specific NG222 recommendation tested by this wording. Watchful waiting and low-intensity guided self-help are inappropriate for persistent severe depression. Psychosurgery is not a routine further-line treatment for depression and would not precede established physical treatments such as ECT.

Reference: NICE, Depression in adults: treatment and management (NG222), section 1.13.1, 2022; current following January 2026 exceptional surveillance. https://www.nice.org.uk/guidance/ng222/chapter/Recommendations