Major depressive disorder — assessment and stepped management (MEQ)

(i) Assessment priorities. Structure as risk, bipolarity, substances, medical exclusion, MSE, collateral, capacity and social context. Risk: expand item 9 into full assessment — ideation frequency, intent, plan, means (medications, access at home), prior attempts, hopelessness, protective factors (children, work identity, religion), alcohol-related impulsivity. Bipolar screen: elevated/irritable periods, reduced sleep need, grandiosity, risky spending/sex, postpartum mood events, family history of bipolar. Alcohol: quantity, withdrawal risk, contribution to insomnia and mood. Medical: thyroid, anaemia, B12 if indicated, medications, pregnancy status if relevant. Baseline bloods and ECG before antidepressant if indicated by age/cardiac risk/agent choice. Collateral from partner if available. Capacity for treatment decisions; voluntary care preferred if safe.^[4][5]

(ii) Working diagnosis and differentials. Working diagnosis: recurrent major depressive disorder, current episode moderate-severe (melancholic-leaning neurovegetative features), with alcohol use disorder comorbidity contributing. Differentials: bipolar depression (must remain active until screen complete); substance-induced depressive disorder (alcohol may fully or partly explain — dual formulation); persistent depressive disorder with superimposed episode; adjustment disorder (too severe/neurovegetative here); medical (hypothyroid etc.); grief (not described). Discriminators: longitudinal mania/hypomania, timeline with alcohol, TSH/labs, psychosis absence/presence.^[4]

(iii) Initial management. Collaborative safety plan and means restriction (secure surplus medications; reduce alcohol). Psychoeducation. Offer evidence-based psychotherapy (CBT or IPT) and lifestyle structure (sleep, activity scheduling). Named first-line drug example: sertraline 50 mg orally each morning, review in 1–2 weeks for activation/suicidality and side-effects, titrate toward 100 mg if tolerated and incomplete response, plan 4–6 weeks at therapeutic dose with serial PHQ-9. Monitoring: sexual side-effects, GI symptoms, hyponatraemia risk if older/comorbid, interactions. Address alcohol with motivational work and withdrawal risk assessment. Crisis contacts and early review. Do not stop at a 3-month course if remits — plan maintenance counselling later.^[2][4]

(iv) STAR*D sequential logic. Measurement-based care improves systematic dose adjustment. Roughly one-third remit at first-step SSRI; non-remitters move to switch (alternative antidepressant) or augment depending on partial vs non-response and tolerability; further steps include lithium or T3 augmentation and more complex combinations, with diminishing cumulative remission — so avoid random polypharmacy and re-check diagnosis/adherence/substances at each step.^[1][2]

(v) ECT threshold. Escalate to ECT if she develops psychotic features, catatonia, life-threatening poor intake, rapidly escalating suicide risk not containable in current setting, or true treatment resistance after adequate trials — ECT is highly effective in severe depressive disorders and is not only a last resort after endless incomplete trials.^[3]