Select the most appropriate initial pharmacological or procedural intervention for each of the following patients presenting with distinct clinical features of major depressive disorder.
- A 72-year-old man with a 4-week history of profound psychomotor retardation, somatic delusions that his internal organs are rotting, and complete refusal to consume any food or fluids.Electroconvulsive therapy
- A 55-year-old man presenting with a 3-month history of significant unintentional weight loss (9 kg), poor appetite, and severe initial and middle insomnia, leading to severe daytime fatigue.Mirtazapine
- A 48-year-old woman with a newly diagnosed major depressive episode who is also experiencing chronic, bilateral, burning stocking-glove paresthesias secondary to poorly controlled diabetes mellitus.Duloxetine
- A 29-year-old woman with a 6-week history of major depressive disorder characterized by prominent lethargy and hypersomnia. She strongly emphasizes her desire to avoid any medication that may cause weight gain or sexual dysfunction.Bupropion
Answer
The clinical profiles map to interventions based on side effect profiles and comorbidities: the psychotic/refusing food patient matches with Electroconvulsive therapy; the insomniac/anorexic patient matches with Mirtazapine; the diabetic neuropathy patient matches with Duloxetine; and the lethargic patient avoiding sexual side effects matches with Bupropion.
Each patient's clinical vignette highlights specific indications for a particular therapy. The elderly man with psychotic depression and food refusal requires the rapid, life-saving response of electroconvulsive therapy. The man with severe insomnia and weight loss benefits from the sedating and appetite-stimulating effects of mirtazapine. The woman with diabetic neuropathy is best treated with duloxetine, an SNRI indicated for both conditions. The young woman with hypersomnia who wishes to avoid sexual dysfunction and weight gain is an ideal candidate for the activating NDRI bupropion.
Step-by-Step Solution
Key Concept
Tailoring depression treatment based on patient-specific symptom clusters, comorbidities, and medication side-effect profiles.