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Difficulty: Very hardDepressive Disorders

A 68-year-old woman is brought to the emergency department by her son due to progressive behavioral changes over the past 5 weeks. She has developed profound sadness, anhedonia, and terminal insomnia, typically waking at 3:00 AM and unable to return to sleep. For the past week, she has refused all food and water, repeatedly stating, "My stomach has turned to dust, it cannot process anything." She has lost 6 kg (13.2 lbs) during this period. Her medical history is significant for Parkinson disease, for which she has been taking carbidopa-levodopa and selegiline for three years.

Vital signs show a blood pressure of 96/60 mmHg and a heart rate of 112/min. Physical examination reveals severely dry mucous membranes and decreased skin turgor.

Laboratory studies show:
TestResultReference Range
Sodium152 mEq/L136-145 mEq/L
Blood urea nitrogen45 mg/dL7-18 mg/dL
Creatinine1.6 mg/dL0.6-1.2 mg/dL
Thyroid-stimulating hormone (TSH)0.1 µU/mL0.5-5.0 µU/mL
Free thyroxine (T4)0.5 ng/dL0.9-1.7 ng/dL

Which of the following is the most appropriate next step in management?

  1. Admit for intravenous hydration and electroconvulsive therapy (ECT)Answer
  2. B
    Initiate fluoxetine monotherapy and plan to discontinue if ineffective after 2 weeks
  3. C
    Initiate sertraline and olanzapine
  4. D
    Diagnose brief psychotic disorder and initiate haloperidol
  5. E
    Initiate intravenous hydration and levothyroxine

Answer

Admit for intravenous hydration and electroconvulsive therapy (ECT)
This patient presents with a severe episode of Major Depressive Disorder (MDD) with psychotic features (Cotard delusion, i.e., the belief that her stomach has turned to dust) and melancholic features (terminal insomnia, profound weight loss). Her absolute refusal to eat or drink has resulted in severe dehydration, hypernatremia, and prerenal azotemia, representing a life-threatening psychiatric emergency. In cases of psychotic depression complicated by active starvation, severe suicidality, or when standard medications are contraindicated, Electroconvulsive therapy (ECT) is the gold-standard treatment due to its rapid onset and high efficacy. Intravenous hydration must be provided concurrently to stabilize her medical condition.

Step-by-Step Solution

1
Identify the primary psychiatric syndrome based on the clinical presentation.
The patient has 5 weeks of melancholic depression and recent onset of somatic delusions, leading to a diagnosis of Major Depressive Disorder (MDD) with psychotic features.
Accurate diagnosis is required to guide psychopharmacologic or procedural interventions.
2
Assess clinical acuity and immediate life threats.
The patient's delusion has led to absolute food and fluid refusal, resulting in severe dehydration (hypernatremia) and acute kidney injury (prerenal azotemia).
Conditions involving active starvation or imminent danger to self necessitate rapid, aggressive intervention.
3
Evaluate the patient's medication list for potential pharmacological constraints.
The patient takes selegiline, a monoamine oxidase B (MAO-B) inhibitor. Initiating standard first-line therapies for psychotic depression (like SSRIs or SNRIs) is strictly contraindicated.
Combining serotonergic agents with an MAOI carries a high risk of precipitating fatal serotonin syndrome.
4
Determine the optimal intervention balancing efficacy, speed, and safety.
Electroconvulsive therapy (ECT) combined with supportive medical care (IV hydration) is the safest and most effective choice.
ECT provides rapid symptom relief for life-threatening psychotic depression and bypasses the dangerous drug-drug interactions posed by her Parkinson disease medications.

Key Concept

Management of severe major depressive disorder with psychotic features and life-threatening food refusal
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Topics

Depressive Disorders

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