Psychotic depression — structured clinical viva

Diagnosis. Major depressive episode, severe, with mood-congruent psychotic features (nihilistic/guilt delusions; accusatory hallucinations). Confirm full MDE criteria, impairment, exclusions (substance/organic as far as assessed), and ongoing bipolar vigilance. ^[5]

Risk. Meta-analytic signal for elevated completed suicide in delusional depression — assess intent, plan, means, command quality, food refusal trajectory, and the false reassurance of retardation. Intensity of care and means restriction are part of treatment. ^[3]

Pharmacotherapy. Combination AD+AP. STOP-PD: sertraline + olanzapine superior to olanzapine + placebo for remission. Classic Spiker combination also examinable. Name start doses (e.g. sertraline 50 mg oral daily titrating; olanzapine 5 mg oral night titrating), metabolic and clinical monitoring. Do not offer AP or AD monotherapy as the complete plan. ^[1][6]

ECT. Escalate early if intake collapses, catatonia appears, suicide risk becomes uncontainable, or speed is essential — strong efficacy evidence in severe depression. Consent covers cognitive and anaesthetic risks. ^[4][5]

Continuation. STOP-PD II: after remission on combination, continuing olanzapine with sertraline reduced relapse versus sertraline + placebo — balance metabolic harm, plan duration, and supervised taper only when stable. ^[2]