A 58-year-old woman with severe depression has lost 8 kg in six weeks because of profound appetite loss, expresses nihilistic delusions that her organs have rotted, and refuses food and fluids. She has no cardiac contraindications to anaesthesia. After medical stabilisation, the most appropriate next step in management is:

• A Add lithium augmentation to her current SSRI
• B Start an antipsychotic alone and reassess in eight weeks
• C Switch to phenelzine with dietary tyramine restriction
• D Course of electroconvulsive therapy ✓

Explanation

Psychotic depression with life-threatening food and fluid refusal is a primary indication for electroconvulsive therapy, which achieves faster remission than any pharmacological combination and remains effective when delusions blunt antidepressant response. Waiting eight weeks risks fatal dehydration and malnutrition. Lithium augmentation acts too slowly and does not address psychosis reliably, and initiating a risky MAOI in a medically fragile, non-adherent patient with restricted oral intake is inappropriate when a definitive rapid intervention exists.

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

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Written and medically reviewed by the StethoPrep medical team.