A 74-year-old man is hospitalized due to severe depression and a 9-kg (19.8-lb) weight loss over the last month. The patient has become progressively withdrawn from friends and family, stopped attending his weekly bridge game, and refuses to leave the house to visit his children and grandchildren. He sleeps poorly and ruminates at night about his financial situation and past events such as fighting with his brother when they were adolescents. The patient has a history of depression and responded to treatment with a tricyclic antidepressant 30 years ago. A recent trial of a selective serotonin reuptake inhibitor was ineffective and was discontinued. The patient has a history of controlled hypertension and a myocardial infarction 10 years ago from which he recovered completely. In the hospital, efforts to get him to eat and drink are unsuccessful. On mental status examination, the patient's eyes are downcast and he gives brief, barely audible responses. He reluctantly discloses that he has been hearing the voice of his brother, who died 15 years ago, accusing him of committing multiple crimes. Which of the following is the most appropriate treatment for this patient?

Question

A 74-year-old man is hospitalized due to severe depression and a 9-kg (19.8-lb) weight loss over the last month.  The patient has become progressively withdrawn from friends and family, stopped attending his weekly bridge game, and refuses to leave the house to visit his children and grandchildren.  He sleeps poorly and ruminates at night about his financial situation and past events such as fighting with his brother when they were adolescents.  The patient has a history of depression and responded to treatment with a tricyclic antidepressant 30 years ago.  A recent trial of a selective serotonin reuptake inhibitor was ineffective and was discontinued.  The patient has a history of controlled hypertension and a myocardial infarction 10 years ago from which he recovered completely.  In the hospital, efforts to get him to eat and drink are unsuccessful.  On mental status examination, the patient's eyes are downcast and he gives brief, barely audible responses.  He reluctantly discloses that he has been hearing the voice of his brother, who died 15 years ago, accusing him of committing multiple crimes.  Which of the following is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

11ec25c8_d7ba_4b4b_bc81_696b75572f76_MD0003_00 This patient's severe depression, loss of interest, excessive guilt, sleep and appetite disturbance, and auditory hallucinations are consistent with major depression with psychotic features. His marked weight loss and refusal to eat and drink require urgent treatment. According to multiple evidence-based guidelines, first-line treatment of psychotic depression consists of either an antidepressant plus an antipsychotic or electroconvulsive therapy (ECT). Because ECT is generally faster than pharmacotherapy, it is used to achieve a rapid response in depressed elderly patients who are unable to eat and drink, psychotic, or actively suicidal. ECT involves inducing a 30- to 60-second generalized tonic-clonic seizure. Hemodynamic changes are brief and cardiac complications are rare. Amnesia (typically short-lived) is one of the most common side effects. Antidepressants typically take up to 6-8 weeks for response and must be combined with an antipsychotic medication to effectively treat major depression with psychotic features (Choices D, E, and F). Although the patient's condition previously responded to a tricyclic antidepressant, antidepressant monotherapy would now be inadequate, and ECT is preferred due to the need for rapid response in this severely depressed patient who is not eating or drinking. (Choice A) Antipsychotic monotherapy would not adequately treat this patient's depression. The combination of an antidepressant and an antipsychotic would be appropriate in a less urgent situation. (Choice B) Cognitive-behavioral therapy alone would not be sufficient due to the severity of depression, presence of psychotic features, and need for rapid response. Educational objective: Electroconvulsive therapy is an evidence-based treatment for major depression that carries a low risk for complications. It is a first-line treatment for major depression with psychotic features and appropriate for severely depressed elderly patients who are not eating or drinking and require rapid intervention. References: The role of electroconvulsive and neuromodulation therapies in the treatment of geriatric depression. (http://www.ncbi.nlm.nih.gov/pubmed/24229660) ECT in treatment-resistant depression. (http://www.ncbi.nlm.nih.gov/pubmed/23212054)

A 74-Year-Old Man Is Hospitalized Due to Severe Depression and a 9-Kg