A 72-year-old woman is admitted to the hospital because of worsening suicidal ideation for the past month. The patient has been refusing meals in order to "sacrifice" herself for "the greater good." She has stopped communicating with her family and spends most of her days sleeping or staring at the television. The patient has been treated with multiple antidepressants in the past for recurrent major depressive disorder. Two weeks ago, she discontinued taking venlafaxine because she felt it "interfered" with her plan to kill herself. The patient is 165 cm (5 ft 5 in) tall and weighs 48 kg (105 lb). BMI is 17.5 kg/m2. Physical examination shows decreased skin turgor and dry mucous membranes. Which of the following is the best next step in management?

Question

A 72-year-old woman is admitted to the hospital because of worsening suicidal ideation for the past month.  The patient has been refusing meals in order to "sacrifice" herself for "the greater good."  She has stopped communicating with her family and spends most of her days sleeping or staring at the television.  The patient has been treated with multiple antidepressants in the past for recurrent major depressive disorder.  Two weeks ago, she discontinued taking venlafaxine because she felt it "interfered" with her plan to kill herself.  The patient is 165 cm (5 ft 5 in) tall and weighs 48 kg (105 lb).  BMI is 17.5 kg/m2.  Physical examination shows decreased skin turgor and dry mucous membranes.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

11ec25c8_d7c0_dafd_bc81_113e9768fd86_MD0003_00 This patient's severe depression with delusions is consistent with major depressive disorder (MDD) with psychotic features. Her condition is a psychiatric emergency because she is suicidal, refusing to eat, and has become dehydrated (decreased skin turgor and dry mucous membranes on physical examination). First-line treatment of psychotic depression consists of either the combination of an antidepressant and antipsychotic or electroconvulsive therapy (ECT). ECT works faster than pharmacotherapy and is often preferred to achieve a rapid response in depressed elderly patients who are unable to eat and drink, psychotic, or actively suicidal. ECT induces a 30- to 60-second generalized tonic-clonic seizure under general anesthesia. ECT is a safe and effective treatment for severe major depressive disorder and has no absolute contraindications. It is typically administered 3 times a week for a course of 6-12 treatments. (Choices A and E) Clozapine is primarily reserved for use in treatment-resistant schizophrenia due to the risk of agranulocytosis. Antipsychotic monotherapy with olanzapine would not adequately treat this patient's depression. The combination of an antidepressant and an antipsychotic would be appropriate for MDD with psychotic features in a nonemergency situation. (Choice B) This patient is not communicating and would be unable to participate in cognitive-behavioral therapy. Psychotherapy alone would be inadequate due to the severity of depression, presence of psychotic features, and need for rapid response. (Choices D and F) The tricyclic antidepressant imipramine and the monoamine oxidase inhibitor phenelzine can be considered for patients with treatment-resistant depression. However, antidepressants do not work as fast (may take up to 6-8 weeks for response) as ECT and must be combined with an antipsychotic medication to effectively treat MDD with psychotic features. ECT would be preferred given the need for rapid response. Educational objective: Electroconvulsive therapy is a safe and effective first-line treatment for major depressive disorder with psychotic features. It is particularly appropriate for severely depressed patients who refuse to eat and drink or are acutely suicidal. References: The role of electroconvulsive and neuromodulation therapies in the treatment of geriatric depression. (http://www.ncbi.nlm.nih.gov/pubmed/24229660) Neuromodulation therapies for geriatric depression. (http://www.ncbi.nlm.nih.gov/pubmed/25995098) Key updates in the clinical application of electroconvulsive therapy. (http://www.ncbi.nlm.nih.gov/pubmed/28406327)

A 72-Year-Old Woman Is Admitted to the Hospital Because of Worsening