A 62-year-old woman with major depressive disorder presents with mutism, waxy flexibility, and stupor for 5 days. She has not eaten or drunk fluids for 48 hours. Her depressive episode is severe with mood-congruent psychotic features. Which is the most appropriate next step in management?

• A Start fluoxetine 20 mg daily and review in 2 weeks
• B Electroconvulsive therapy (ECT) ✓
• C Add lithium augmentation to her current antidepressant
• D Start olanzapine 5 mg daily as monotherapy

Explanation

ECT is the treatment of choice for severe depression with catatonic features, especially when food and fluid refusal creates an urgent medical situation. ECT is also highly effective for depression with psychotic features. Antidepressants and antipsychotics take weeks to work and are inappropriate as sole initial therapy when the patient is stuporous and not eating or drinking.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

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