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Herein, we report a case of an 83-year-old man with vascular depression associated with musical hallucinations. Brain magnetic resonance imaging disclosed diffuse brain atrophy with multiple higher-density zones in the white matter and basal ganglia. Single photon emission computed tomography images showed areas of hypoperfusion in the bilateral temporal lobe and basal ganglia. Combination treatment with paroxetine and a low dose of risperidone rapidly improved both the depressive symptoms and musical hallucinations.