A 58-year-old man presents with a three-month history of profound low mood, early morning awakening, 8 kg weight loss, and firm convictions that he has committed unpardonable sins and that his family will be ruined financially because of him. He is eating poorly and refuses to leave his room. Which is the best initial pharmacological strategy?

• A Combination of an antidepressant and an antipsychotic ✓
• B SSRI alone at standard dose
• C Antipsychotic alone
• D Benzodiazepine alone until mood improves

Explanation

Delusional depression (major depressive disorder with mood-congruent psychotic features: guilt and nihilistic or poverty delusions) responds poorly to antidepressant monotherapy. Standard practice, supported by controlled trials, is combined antidepressant plus antipsychotic treatment; ECT is an alternative when rapid response is needed or food intake is critically compromised. Antipsychotic monotherapy leaves the depressive core untreated, and benzodiazepines have no antidepressant effect despite calming agitation.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.