MS depression, suicide risk, PBA, and steroid mania (MEQ)

(i) Formulation and differentials. Concurrent cluster: (a) steroid-associated manic/irritable affective state temporally linked to high-dose methylprednisolone; (b) likely major depression with passive suicidal ideation requiring full risk assessment (Goldman priority: MS depression is under-treated); (c) probable pseudobulbar affect (brief uncontrollable crying without sadness — not the same as depressive crying or bipolar lability); (d) subjective cognitive slowing with vocational threat.^[1][8] Differentials: delirium/infection; primary bipolar disorder unmasked by steroids; interferon-related mood contribution versus multifactorial depression; pure demoralisation without MDD.^[2][7]

(ii) Acute management. Joint neurology: review steroid course (stop further pulses/taper as medically appropriate), exclude infection/metabolic delirium, ensure sleep and safety, use short-term sedation/antipsychotic strategies if agitation or psychosis risk is high, capacity assessment. Explicit suicide assessment (ideation, plan, intent, means, supports) and crisis pathway if needed — MS does not lower the threshold for care.^[2][6]

(iii) Depression and PBA. Depression: offer CBT, including telephone-delivered models for access; pharmacotherapy options include SSRIs with MS-relevant trial discussion of paroxetine (e.g. start 10 mg oral daily, titrate carefully with monitoring for sexual side effects, hyponatraemia, suicidality).^[4][5] PBA: educate; where available dextromethorphan 20 mg/quinidine 10 mg oral per product schedule with QT/interaction checks; if unavailable, pragmatic SSRI discussion and neurology liaison.^[3][8]

(iv) DMT, cognition, disposition. Do not stop interferon unilaterally for mood alone — multifactorial formulation and shared decision with neurology, acknowledging pharmacoepidemiologic context of antidepressant use across DMT classes.^[7] Cognitive screening/neuropsychology if work threatened; MS clinic + mental health follow-up; safety plan; partner education about PBA versus mood. ^[2][6]