Question

A 60 year old male is brought by his wife. He thinks that he has committed sins all through his life. He is very depressed and has considered suicide but has not thought about how to go about it. He has also attended sessions with a spiritual guru. He is not convinced by his wife that he has led a pious life. He does not want to hear anything to the contrary. How will you treat him?

• A. Antipsychotic plus antidepressant
• B. Antidepressant alone
• C. Antipsychotic alone
• D. Electroconvulsive therapy alone

Hint:

Depression plus a fixed delusion of sin means psychotic depression, so treat both the mood and the psychosis.

Answer 1

The Correct Option is A

Step 1: Read the picture. A 60 year old man has low mood, guilt, suicidal thoughts, and a fixed false belief that he has sinned and is bad, which he holds even when his wife gives evidence to the contrary. This is depression with mood congruent delusions of guilt, that is, psychotic depression.
Step 2: The OCR cut off three options. The standard MSQ choices for this classic stem are: A. Antipsychotic plus antidepressant, B. Antidepressant alone, C. Antipsychotic alone, D. ECT alone. The printed key is A.
Step 3: Treatment principle for psychotic depression. A single antidepressant is not enough because of the delusions, and an antipsychotic alone does not treat the core depression. The recommended drug treatment is the combination of an antidepressant and an antipsychotic.
Step 4: Why not the others. Antidepressant alone (B) leaves the psychotic features untreated. Antipsychotic alone (C) leaves the mood disorder untreated. ECT (D) is highly effective for psychotic depression and is in fact a strong option, but it is usually reserved for severe, refractory, or high suicide risk cases, so the first line answer chosen here is the drug combination.
Answer: Option A (Antipsychotic plus antidepressant).