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Question

Difficulty: HardDepressive Disorders

A 72-year-old woman is brought to the emergency department by her son due to worsening confusion and refusal to eat or drink. For the past two months, she has experienced profound sadness, early morning awakenings, and a 9-kg (20-lb) weight loss. One week ago, her primary care physician diagnosed her with depression and started her on sertraline 50 mg daily. The son is unsure if the physician took a detailed psychiatric history. Over the last 3 days, the patient has stopped eating and drinking entirely, stating repeatedly, "My intestines are rotting away because of my sins." Her temperature is 37.1°C (98.8°F), blood pressure is 90/60 mm Hg, heart rate is 112/min, and respiratory rate is 16/min. Physical examination shows remarkably dry mucous membranes and decreased skin turgor.

Laboratory TestResult
Blood urea nitrogen45 mg/dL
Creatinine1.9 mg/dL
Thyroid-stimulating hormone2.1 µU/mL
Free thyroxine1.2 ng/dL

After initiating intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?

  1. Refer for electroconvulsive therapyAnswer
  2. B
    Discontinue sertraline and initiate haloperidol monotherapy
  3. C
    Increase the dose of sertraline to 100 mg daily
  4. D
    Discontinue sertraline and immediately initiate tranylcypromine
  5. E
    Discontinue sertraline and initiate levothyroxine

Answer

The correct answer is referring the patient for electroconvulsive therapy (ECT).
The correct answer is referring the patient for electroconvulsive therapy (ECT). This patient is experiencing a major depressive episode with psychotic features (evidenced by somatic delusions that her intestines are rotting). Furthermore, she has developed life-threatening inanition (complete refusal to eat or drink) leading to severe dehydration and acute kidney injury, as indicated by her hypotension, tachycardia, and elevated blood urea nitrogen and creatinine. While the standard pharmacological treatment for psychotic depression is an antidepressant combined with an antipsychotic, ECT is the first-line, definitive treatment when rapid clinical response is necessary to save the patient's life (e.g., severe suicidality, severe malnutrition, or severe dehydration).

Step-by-Step Solution

1
Identify the primary psychiatric diagnosis based on the timeline and symptoms.
Major depressive disorder with psychotic features.
The patient has a 2-month history of depressive symptoms followed by the recent onset of somatic delusions ("intestines are rotting away").
2
Assess the severity and immediate risks to the patient's health.
Life-threatening inanition and severe dehydration.
The patient has refused food and water for 3 days, leading to hypotension, tachycardia, and acute kidney injury (elevated BUN and creatinine).
3
Determine the most appropriate definitive psychiatric intervention.
Electroconvulsive therapy (ECT).
ECT is the treatment of choice for severe depression when a rapid response is required due to life-threatening conditions like inanition or high suicide risk.

Key Concept

Management of major depressive disorder with psychotic features and life-threatening inanition
Estimated Time:1m 30s
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Topics

Depressive Disorders

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