Late-life depression — structured clinical viva

Formulate as late-life major depression with vascular features and bereavement context, not "normal ageing" or automatic irreversible dementia. Vascular depression is a phenotype linking cerebrovascular disease to depression with executive dysfunction — useful for prognosis and treatment expectations, not a separate DSM code.^[1][5]

The sertraline 25 mg trial is inadequate (token dose / incomplete titration). Re-check adherence, bipolarity, substances, medical contributors, sodium if any SSRI exposure, cognition with collateral, and suicide risk with means. Then treat to a therapeutic dose of a suitable agent or switch, with sodium and falls monitoring, while offering adapted psychotherapy and addressing isolation/grief.^[5][6]

If severe melancholic/psychotic features, high risk, or true non-response after adequate trials, discuss ECT early using PRIDE-informed framing of efficacy in geriatric depression.^[3] Older adults have high suicide lethality — ask directly and restrict means.^[4] After recovery, plan maintenance antidepressant rather than early cessation (Reynolds NEJM 2006).^[2]