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ECT for Refractory Psychotic Depression — MRCPsych Paper B MCQ

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ModerateMood DisordersECT for Refractory Psychotic DepressionMRCPsych Paper B

A 54-year-old inpatient has a severe depressive episode with mood-congruent delusions and marked psychomotor retardation. Adherence to an adequate-dose combined antidepressant and antipsychotic regimen has been confirmed, but there has been no meaningful improvement after an adequate treatment period. What is the most appropriate next treatment to consider?

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Correct answer: E — Arrange assessment for electroconvulsive therapy

The correct answer is E. NICE recommends considering ECT for severe depression when other treatments have been unsuccessful; it may also be considered when a rapid response is required or following an informed patient preference. This patient has severe psychotic depression with confirmed non-response to an adequate combined antidepressant–antipsychotic regimen, making ECT assessment an appropriate further-line step. Continuing an ineffective regimen unchanged is not justified. Antidepressant monotherapy would remove the antipsychotic component used to treat psychotic symptoms. Benzodiazepines may provide short-term symptomatic relief for anxiety or agitation but do not treat the depressive or psychotic syndrome. Discharge without an effective treatment plan is inappropriate given the illness severity. ECT requires individual risk–benefit assessment and informed, shared decision-making.

Reference: NICE. Depression in adults: treatment and management (NG222), section 1.13.1, Electroconvulsive therapy for depression. 2022; reviewed 2026. https://www.nice.org.uk/guidance/ng222/chapter/Recommendations