A 32-year-old woman has Major Depressive Disorder with psychotic features. She refuses ECT. Which pharmacological combination is the most appropriate initial treatment?
- A Antidepressant monotherapy with fluoxetine 40 mg
- B Antipsychotic monotherapy with haloperidol 5 mg
- C Combination of an antidepressant (SSRI/SNRI) plus an atypical antipsychotic (e.g., olanzapine + fluoxetine, or quetiapine) ✓
- D Mood stabilizer (lithium) plus antipsychotic
Explanation
Major Depressive Disorder with Psychotic Features ('psychotic depression') requires combination treatment with both an antidepressant and an antipsychotic. Antidepressant monotherapy is insufficient and may worsen psychosis. Antipsychotic monotherapy does not adequately treat the depressive component. The combination of olanzapine + fluoxetine (Symbyax) has FDA approval for psychotic depression. Quetiapine as monotherapy has some evidence but combination therapy is preferred. ECT is the most effective treatment but when refused, pharmacological combination is the standard of care. Lithium is used for bipolar depression, not unipolar psychotic depression.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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