Evaluate the clinical scenarios below and match each patient to the most appropriate next step in psychiatric management.
- A 31-year-old primigravida at 14 weeks gestation is brought for urgent psychiatric evaluation. She exhibits profound psychomotor retardation and a steadfast, delusional belief that her internal organs are decomposing. She has refused all food and fluids for five days and appears severely dehydrated.Admit to an inpatient psychiatric unit and prepare for electroconvulsive therapy (ECT).
- An otherwise healthy 24-year-old woman seeks help for a two-month history of sleeping 14 hours a day, hyperphagia, and severe depressed mood. Her medical history reveals a hospitalization three years ago following a two-week period of sleeplessness, pressured speech, and grandiose delusions. She currently takes no medications.Begin monotherapy with quetiapine.
- Three weeks following an anterior ST-elevation myocardial infarction complicated by heart failure, a 58-year-old man develops pervasive sadness, feelings of worthlessness, and passive suicidal ideation that severely impacts his cardiac rehabilitation.Start treatment with sertraline.
- A 52-year-old man with chronic, severe depression presents for consultation. He continues to experience debilitating anhedonia despite documented, adequate therapeutic trials of escitalopram, duloxetine, and venlafaxine augmented with aripiprazole. He adamantly refuses electroconvulsive therapy due to fears of memory impairment.Initiate treatment with intranasal esketamine alongside a new oral antidepressant.
Answer
The pregnant patient with inanition requires inpatient admission and ECT. The 24-year-old woman with a history of mania requires quetiapine monotherapy. The post-MI patient should be started on sertraline. The patient with treatment-resistant depression refusing ECT should receive intranasal esketamine.
Each correct pairing matches a nuanced psychiatric presentation with its safest and most evidence-based management strategy. ECT provides the rapid response required for inanition in pregnancy. Quetiapine treats bipolar depression without risking manic switch. Sertraline provides cardiac safety post-MI. Esketamine bypasses treatment resistance when ECT is refused.
Step-by-Step Solution
Key Concept
Management of depressive disorders requires tailoring interventions to specific subtypes (e.g., psychotic features), identifying bipolar vs. unipolar disease to avoid manic switch, ensuring cardiovascular safety in comorbid patients, and escalating to interventional therapies for treatment resistance.