Case debrief

The patient has clear MDD with risky suicidal features

He was treated with aggressive medication changes to better treat these symptoms and improve tolerability of his regimen

His diagnosis was complicated by intrusive images

• – When first reported, appeared to be classic obsessions as described in DSM-5

• – However, clearly these were externally experienced like psychotic visual and auditory hallucinations that developed after his MDD began

Despite the medication changes and maximized psychosocial supports, the patient continued to be suicidal and eventually his safety could not be guaranteed

The patient did not want to go to an inpatient hospital and astutely asked if there were any treatments that were faster that could be used to lower his symptoms to avoid a hospital stay

• – Round the clock observation was arranged by family members at home

• – Outpatient ECT was arranged

  • The patient received seven treatments over two to three weeks

  • Tolerated these procedures well with the usual post-ECT fatigue and anterograde amnesia

MDD symptoms based on the IDS lowered from severe depression (43) to remission (3)

He continues escitalopram (Lexapro) 30 mg/d, asenapine (Saphris) 10 mg/d, and weekly supportive psychotherapy

He has no side effects, including the absence of EPS, weight gain, and metabolic disorder

In retrospect, he is more definitively diagnosed with psychotic MDD as OCD tends not to respond to ECT treatments, where typically only anecdotal case reports support its use

Take-home points

Psychotic MDD often has guilt-based delusions, but sometimes hallucinations may be the principal psychotic symptom, as in this case

Atypical antipsychotics are plentiful and numerous

• – They are all equally effective for psychosis in schizophrenia but have unique side-effect profiles that may affect individual tolerability

Sometimes, several atypical antipsychotics must be tried in sequence to obtain the best balance of efficacy and tolerability

ECT is very effective in treating psychotic MDD

Performance in practice: confessions of a psychopharmacologist

What could have been done better here?

Simply escalating and waiting for high-dose SSRI effectiveness may have avoided side effects associated with trials of a myriad of atypical antipsychotics

Occasionally depressive psychoses respond to SSRI alone

Despite his young age of 18, ECT could have been provided earlier

Possible action items for improvement in practice

Research the differential diagnostic dilemmas between MDD with psychosis versus OCD

Research the use of ECT in young adults

Tips and pearls

Atypical antipsychotics appear to be roughly equal in efficacy in treating schizophrenia and in many cases of bipolar mania

Atypical antipsychotics are not equal in treating depressive disorders, as at present, only olanzapine, quetiapine, aripiprazole, brexpiprazole and lurasidone are approved for depressive disorder treatment

Atypical antipsychotics are relatively understudied in the treatment of anxiety disorders and there are no approvals

Choose an atypical antipsychotic based on approval status, evidence base availability, and its purported mechanisms of action

Otherwise, it is often wise to choose based on side effect profiles

• – Sedating or not

• – Weight-gain-promoting or not

• – EPS-prone or not

• – QTc prolongation-promoting or not

Two-minute tutorial

Acute suicide risk