A 45-year-old woman with severe, treatment-resistant major depressive disorder with psychotic features fails multiple antidepressant and antipsychotic trials. She has expressed suicidal ideation. Which treatment has the HIGHEST response rate and most rapid onset of action for this presentation?

• A Adding lithium augmentation to existing antidepressant
• B High-dose SSRI + antipsychotic for 12 weeks
• C Electroconvulsive therapy (ECT) ✓
• D Transcranial magnetic stimulation (TMS) daily for 6 weeks

Explanation

ECT is the most effective treatment for severe, treatment-resistant major depressive disorder, particularly with psychotic features, catatonia, or in the context of imminent suicidal risk requiring rapid response. Response rates for ECT in psychotic depression reach 80–90%, significantly higher than any pharmacological approach. ECT has a rapid onset (often improvement within 2–3 sessions), making it the treatment of choice when rapid response is critical. TMS is effective but slower and less efficacious in psychotic or severe depression. Lithium augmentation is a viable strategy but has slower onset and lower efficacy in psychotic depression.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.