From the Research
The best next step for this 79-year-old patient with major depressive disorder (MDD) with psychotic features who has significant weight loss and is refusing medications would be to pursue involuntary hospitalization for psychiatric treatment. This patient is experiencing a life-threatening situation due to the severe weight loss and medication refusal, which indicates they lack the capacity to make safe healthcare decisions. Once hospitalized, the treatment team should initiate electroconvulsive therapy (ECT) as the most appropriate intervention, given the patient's age, psychotic features, and severe nutritional compromise, as supported by a case report suggesting the therapeutic benefit of ECT in patients with psychotic depression 1. ECT is particularly effective for geriatric patients with psychotic depression and can produce rapid improvement in both mood and psychotic symptoms, often when medications have failed or cannot be administered. During hospitalization, nutritional support should be provided, potentially including temporary nasogastric feeding if necessary. After stabilization with ECT, medication therapy could be initiated, typically with an antidepressant combined with an antipsychotic, such as olanzapine, which has been shown to be effective in treating depression with psychotic features 2. Additionally, the use of benzodiazepines may be considered to reduce relapse and recurrence rates in patients with severe MDD with psychotic features, as suggested by a study published in 2020 3. However, the most recent and highest quality study, a case report from 2022, suggests that intranasal esketamine may be a promising treatment option for patients with severe major depressive disorder with psychotic features, although larger studies are needed to confirm its effectiveness and safety 4. Given the patient's condition and the available evidence, involuntary hospitalization and initiation of ECT, followed by medication therapy, is the most appropriate course of action.
Some key points to consider in the treatment of this patient include:
- The importance of addressing the patient's severe weight loss and nutritional compromise
- The effectiveness of ECT in treating geriatric patients with psychotic depression
- The potential benefits and risks of using benzodiazepines and intranasal esketamine in patients with severe MDD with psychotic features
- The need for careful monitoring and adjustment of medication therapy to ensure the patient's safety and optimal treatment outcomes. It is also important to note that the patient's condition may lead to misdiagnosis of dementia, as suggested by a case report and review of the literature 1. Therefore, a comprehensive diagnostic evaluation and careful consideration of the patient's overall clinical presentation are essential in developing an effective treatment plan.