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Psychotic Depression in Elderly — MRCPsych Paper B MCQ

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ModerateOld Age PsychiatryPsychotic Depression in ElderlyMRCPsych Paper B

A 70-year-old man is under specialist mental health care for a severe unipolar depressive episode. Despite an adequate trial of an SSRI, he remains depressed and has developed a fixed, mood-congruent delusion that he caused a recent natural disaster. He has no history of mania or hypomania, is eating and drinking, and does not require an urgently rapid response. According to NICE NG222, which treatment is the most appropriate next option to consider?

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Correct answer: B — Antidepressant plus antipsychotic

The correct answer is B. NICE NG222 recommends considering an antidepressant combined with an antipsychotic, such as olanzapine or quetiapine, for depression with psychotic symptoms. Treatment should occur within specialist mental health services, with monitoring of depressive and psychotic symptoms and adverse effects. Antipsychotic monotherapy is not the recommended pharmacological approach because it does not adequately treat the depressive syndrome. Mood stabiliser combinations are more relevant when bipolarity is present, which the stem excludes. ECT is an important option for severe depression when a rapid response is needed, other treatments have been unsuccessful, or the patient prefers it based on previous benefit; it is not automatically required solely because psychotic symptoms are present. NICE characterises the evidence for combination medication as limited, so efficacy should not be overstated.

Reference: National Institute for Health and Care Excellence. Depression in adults: treatment and management (NG222), section 1.12, Psychotic depression, recommendation 1.12.2, 2022; last reviewed 30 January 2026. https://www.nice.org.uk/guidance/ng222/chapter/Recommendations