Two patients with a psychotic depression showed insufficient response to pharmacotherapy and electroconvulsive therapy. The problem therefore was which alternative treatment options should be considered at this stage. On the bases of the available literature the most suitable options seemed to be clozapine, a monoamine oxidase inhibitor and lithium addition. Patient A responded well to clozapine and the condition of patient B improved during treatment with tranylcypromine, lithium and quetiapine.