A 55-year-old woman with severe, medication-refractory bipolar depression has failed 3 adequate antidepressant trials including augmentation. She has persistent suicidal ideation with a plan. Which is the MOST appropriate next step in treatment?

• A Add ketamine infusions (sub-anaesthetic dose IV)
• B Refer for Electroconvulsive Therapy (ECT) ✓
• C Add a fourth antidepressant in combination
• D Initiate clozapine for refractory depression

Explanation

ECT is the most effective treatment for severe treatment-refractory depression, with response rates of 70–90% even in medication-resistant cases. It is the treatment of choice for: treatment-resistant depression, severe MDD with active suicidal risk, psychotic depression, catatonia, and mania unresponsive to pharmacotherapy. The combination of medication-refractoriness AND active suicidality with a plan makes ECT the safest and most rapidly effective intervention. Ketamine infusions have evidence for rapid antisuicidal effects but are not yet first-line for refractory depression in the Indian context. Clozapine has evidence for antisuicidal effects in schizophrenia/bipolar but is not a first-line for refractory depression.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.