Late-life depression — assessment and management (MEQ)

(i) Assessment priorities. Risk first: expand passive death wishes into full assessment — frequency, intent, plan, preparatory acts, access to the firearm and surplus medications, hopelessness, alcohol, protective factors (children, farm identity, faith). Immediate means restriction discussion and same-day safety plan with family/supports as appropriate. Cognitive screen (attention, orientation, memory, executive tasks) plus collateral; do not diagnose irreversible dementia on a single distressed interview. Medical exclusion: delirium screen, TSH, FBC, U&E (baseline sodium before SSRI), B12/folate, glucose control, medication review (diuretic, anticholinergics). Bipolar screen. Vascular risk formulation. Functional status and isolation. Capacity for treatment decisions; least-restrictive legal framework if risk escalates (jurisdiction-specific statutes).^[6][7][8]

(ii) Working diagnosis and differentials. Working diagnosis: late-onset major depressive episode of moderate–severe severity in the context of bereavement and vascular risk, with depression-related cognitive complaints. Vascular depression phenotype is plausible given hypertension/diabetes and executive-style cognitive complaints — a construct linking cerebrovascular disease to late-life depression, not a separate DSM code.^[1][8] Differentials: prolonged grief without full MDD (less likely given neurovegetative cluster and GDS); dementia or mild cognitive impairment (needs reassessment after mood treatment); delirium (acute fluctuating attention — not described as primary here); substance-induced; medical mimics (thyroid, B12); bipolar depression until screen complete; adjustment disorder (too severe/neurovegetative). Discriminators: time course, MSE, labs, collateral cognitive trajectory, response to treatment over time.^[8]

(iii) Initial management. Collaborative safety plan; urgent firearm security. Psychoeducation for patient and family. Offer adapted psychotherapy (IPT for grief/role transition; CBT or behavioural activation) and consider collaborative-care style follow-up intensity.^[2][6] Named first-line example: sertraline 25 mg orally daily for several days then 50 mg daily, early review (1–2 weeks) for activation/suicidality and side-effects, titrate toward 100 mg if tolerated and incomplete response, plan adequate trial at therapeutic dose with serial GDS/PHQ-9. Monitoring: baseline and early repeat sodium (diuretic + age + SSRI = SIADH risk), falls, GI symptoms, bleeding risk, adherence. Optimise medical comorbidity; address isolation and bereavement support. Crisis contacts and clear escalation pathway.^[4][6][8]

(iv) ECT threshold. Escalate to ECT if psychotic features, catatonia, life-threatening poor intake, rapidly escalating uncontainable suicide risk, or non-response after adequate treatment trials — ECT has strong efficacy in severe depressive disorders and is not only a last resort after endless incomplete community trials.^[5]

(v) Maintenance. After remission, plan continuation/maintenance antidepressant rather than stopping at first wellness; randomised evidence in older adults supports maintenance treatment to reduce recurrence. Duration individualised by episode number, severity, residual symptoms, and patient preference, with ongoing psychosocial supports.^[3][6]