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Question

Difficulty: MediumDepressive Disorders

For each of the following clinical scenarios involving a depressive presentation or its treatment, select the most appropriate next step in management.

  • A 74-year-old hospitalized patient with major depressive disorder who refuses all oral intake, exhibits profound psychomotor retardation, and repeatedly states that his internal organs are rotting.Electroconvulsive therapy
  • A 32-year-old outpatient whose severe low mood remitted on fluoxetine, but who now presents with three days of decreased need for sleep, pressured speech, and reckless spending.Discontinue current pharmacotherapy and initiate an atypical antipsychotic
  • A 46-year-old outpatient whose feelings of worthlessness and anhedonia improved significantly on escitalopram, but who is now highly distressed by new-onset delayed ejaculation.Cross-taper to bupropion
  • A 27-year-old primigravida at 9 weeks gestation presenting with a two-month history of mild fatigue, tearfulness, and low mood, with fully intact functional status and no suicidal ideation.Initiate cognitive behavioral therapy

Answer

The correct matches align life-threatening psychotic depression with electroconvulsive therapy, antidepressant-induced mania with stopping the SSRI and starting an antipsychotic, SSRI-induced sexual dysfunction with a switch to bupropion, and mild early-pregnancy depression with cognitive behavioral therapy.
Each clinical scenario presents a unique challenge in the treatment of depressive disorders. ECT provides the necessary rapid relief for life-threatening psychotic depression. Antidepressant-induced mania necessitates stopping the inciting SSRI and starting an antimanic agent. Bupropion avoids the serotonergic sexual side effects common with SSRIs. Psychotherapy is the safest starting point to avoid fetal medication exposure in mild perinatal depression.

Step-by-Step Solution

1
Evaluate the 74-year-old patient with food refusal and delusions.
Identified as major depressive disorder with psychotic features and life-threatening poor intake.
Dictates the need for rapid, definitive somatic treatment because waiting for pharmacotherapy to take effect is unsafe.
2
Assess the 32-year-old patient exhibiting pressured speech and decreased sleep while on fluoxetine.
Identified as an acute manic episode precipitated by an antidepressant.
Requires immediate cessation of the provoking agent and initiation of primary mood-stabilizing treatment.
3
Address the 46-year-old patient's complaint of delayed ejaculation while taking escitalopram.
Identified as a common adverse effect of serotonergic therapy.
Prompts a switch to an effective antidepressant that does not primarily affect serotonin, such as bupropion.
4
Determine the optimal intervention for the 27-year-old pregnant patient with mild depression.
Identified psychotherapy as the safest and most appropriate first-line treatment.
Balances effective symptom management with fetal safety during the highly vulnerable first trimester of organogenesis.

Key Concept

The management of depressive disorders requires tailoring therapy to the specific clinical scenario: utilizing electroconvulsive therapy for life-threatening or psychotic depression, identifying and correctly managing medication-induced mania, mitigating specific adverse effects like sexual dysfunction, and employing non-pharmacologic options in high-risk populations such as early pregnancy.
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Topics

Depressive Disorders

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