Major depressive disorder — diagnosis, suicide risk and first-line management

Diagnosis: major depressive disorder (MDD), single episode, moderate-to-severe, without psychotic features. She meets the threshold of ≥5 SIGECAPS symptoms for ≥2 weeks, including both depressed mood and anhedonia, with functional impairment. There is no prior manic/hypomanic episode, so this is unipolar (not bipolar). Organic mimics (hypothyroidism, anaemia, B12 deficiency) have been excluded.^[1]

SIGECAPS present: Sleep (early waking), Interest (anhedonia), Guilt, Energy (fatigue), Concentration, Appetite/weight, Psychomotor not stated, Suicidal ideation (passive). Depressed mood is additional. ^[1]

Severity: Moderate-to-severe — marked functional impairment at work/parenting, vegetative features (early waking, weight loss), and suicidal ideation. Not mild (no pure watch-and-wait). Not psychotic (no delusions/hallucinations). Not catatonic. ^[1]

Suicide risk assessment (mandatory at every contact):

• Ideation: present, passive ("life not worth living")
• Plan / intent / means: denied — currently lower acute intent, but risk is dynamic
• Protective factors: sister support, employment, children, help-seeking
• Risk factors: guilt, hopelessness themes, female sex with perinatal-age stress, recent functional decline
• Document capacity, safety plan, means restriction (medications/alcohol), and next review timing
• Red flags for urgent escalation: active plan, psychosis, severe self-neglect, postpartum harm thoughts, access to lethal means ^[1]

Immediate management — stepped care:

1. Psychoeducation — illness model, delayed antidepressant effect (4–6 weeks), early side effects, when to seek help.
2. Psychological therapy — offer CBT (or IPT); first-line for moderate depression alone or combined with medication.
3. Pharmacological first-line — start an SSRI, e.g. sertraline 50 mg once daily (or escitalopram 10 mg OD; fluoxetine 20 mg OD). Prefer sertraline for relative safety in overdose and broad evidence base.^[2]
4. Review at 1–2 weeks for suicidality, adherence, and early adverse effects (GI upset, activation, sexual dysfunction, hyponatraemia risk later). Full efficacy assessed at 4–6 weeks; if partial response, optimise dose before switching.
5. Continue effective antidepressant for at least 6–9 months after remission for a first episode; longer if recurrent.
6. Lifestyle — sleep hygiene, activity scheduling, alcohol reduction, social support.
7. When to escalate — no response after adequate trial → switch SSRI/SNRI or augment; ECT if severe, psychotic, catatonic, life-threatening refusal of food/fluid, or high suicide risk not controllable as an outpatient.^[3]

Disposition: Can usually manage as outpatient with close review if risk remains passive, sister can support, and safety plan is agreed. Admit if risk escalates, support collapses, or severe self-neglect develops. ^[1]