A 42-year-old woman is brought to the office by her husband due to worsening depression. The husband reports that the patient has become increasingly withdrawn over the past month. He says, "She abruptly quit her part-time job, stopped answering the phone, and rarely leaves the house now. Over the past week, she stopped showering and wears the same t-shirt and sweatpants every day." The patient has difficulty falling asleep and wakes up at 4:30 AM and is up for the rest of the day. She has a history of 2 depressive episodes previously treated with fluoxetine and venlafaxine but currently takes no psychiatric medications. Physical examination is remarkable for 4.53 kg (10 lb) weight loss. Laboratory results are within normal limits. On mental status examination, the patient whispers and is slow to respond. She says, "My body is infected with worms." She has no suicidal ideation but says, "I deserve to die; my body is decaying from the inside anyway." Which of the following is the most appropriate treatment for this patient?
This patient's worsening depression and development of delusions are consistent with major depressive disorder (MDD) with psychotic features. MDD with psychotic features is a severe subtype of depression characterized by delusions and/or hallucinations. Psychotic features typically have depressive themes such as guilt, worthlessness, and dying (eg, this patient's delusions that her body is decaying and that she deserves to die).
Accurate diagnosis is important because treatment of MDD with psychotic features differs from treatment of nonpsychotic depression (antidepressant monotherapy). First-line treatment consists of an antidepressant plus an antipsychotic (eg, sertraline and risperidone). Electroconvulsive therapy is another first-line option, but it is typically reserved for patients who require rapid response due to severe suicidality or refusal to eat or drink.
(Choices A, D, E, and G) Antipsychotic monotherapy (eg, aripiprazole, quetiapine) or antidepressant monotherapy (eg, mirtazapine, venlafaxine) is not as effective as combination therapy. Patients with MDD with psychotic features should be treated with a combination of an antidepressant plus an antipsychotic.
(Choice B) The combination of 2 antidepressants (the selective serotonin reuptake inhibitor antidepressant, escitalopram, with the dopamine-norepinephrine reuptake inhibitor, bupropion) can be considered for the management of nonpsychotic depression that does not respond to monotherapy alone. However, it would not treat this patient's psychosis.
(Choice C) The combination of an antidepressant (eg, fluoxetine) and lithium is used in the management of treatment-resistant, nonpsychotic depression and bipolar disorder. It is not an effective combination for MDD with psychosis.
Educational objective:
Major depressive disorder with psychotic features is a subtype of depression characterized by severe depression and delusions and/or hallucinations. First-line treatment consists of an antidepressant plus an antipsychotic or electroconvulsive therapy.