A 38-year-old woman presents to the psychiatry clinic with a 3-month history of persistent low mood, loss of interest in her work as a software engineer, and early morning awakening at 4 AM. She reports significant guilt about being a burden to her family, difficulty concentrating on tasks, and a 6 kg weight loss. She denies suicidal ideation but admits to passive death wishes. Her past medical history includes hypothyroidism (TSH normal on levothyroxine). Vital signs are stable; physical examination is unremarkable. What is the most appropriate next step in the management of this patient?

Explanation

## Clinical Assessment This patient meets DSM-5 criteria for Major Depressive Disorder (MDD) with moderate-to-severe features: - Core symptoms: depressed mood, anhedonia (loss of interest) - Neurovegetative signs: early morning awakening, weight loss - Cognitive symptoms: guilt, concentration difficulty - Duration: 3 months (≥2 weeks required) - Functional impairment: occupational dysfunction - Passive death wishes (though no active suicidal plan) **Key Point:** Moderate-to-severe MDD with functional impairment and neurovegetative symptoms warrants combined pharmacotherapy and psychotherapy as first-line treatment. ## Why Sertraline + Psychotherapy is Correct **High-Yield:** The combination of SSRI (first-line antidepressant) and evidence-based psychotherapy (CBT, IPT) is the gold standard for moderate-to-severe MDD [cite:Harrison 21e Ch 470]. - **Sertraline 50 mg daily**: appropriate starting dose for SSRIs; efficacy comparable to other first-line agents (fluoxetine, citalopram, escitalopram) - **Weekly psychotherapy**: CBT or interpersonal therapy (IPT) enhances remission rates and reduces relapse risk - **Timeline**: Response expected in 2–4 weeks; full effect by 8–12 weeks **Clinical Pearl:** Early morning awakening and weight loss suggest endogenous (biological) depression, which typically responds well to pharmacotherapy combined with psychotherapy. ## Why Other Options Are Incorrect **Option 1 (ECT):** Reserved for severe, psychotic, or treatment-resistant MDD; catatonia; or imminent suicide risk. This patient lacks these features. **Option 2 (Fluoxetine alone):** Monotherapy without psychotherapy is less effective than combined treatment for moderate-to-severe MDD. Fluoxetine is equally valid as sertraline but the question stem asks for the most appropriate *next step*, which includes psychotherapy. **Option 3 (Psychotherapy alone):** Insufficient for moderate-to-severe MDD with neurovegetative symptoms. Psychotherapy monotherapy is reasonable only for mild MDD or as augmentation after pharmacotherapy initiation. ## Management Timeline ```mermaid flowchart TD A[MDD diagnosis confirmed]:::outcome --> B{Severity assessment}:::decision B -->|Mild| C[Psychotherapy ± SSRI]:::action B -->|Moderate-Severe| D[SSRI + Psychotherapy]:::action D --> E[Reassess at 4-6 weeks]:::action E --> F{Response?}:::decision F -->|Partial/No| G[Increase dose or switch SSRI]:::action F -->|Good| H[Continue, taper after 6-12 months]:::action ``` **Mnemonic:** **SSRI-CBT** = Standard first-line for moderate MDD (SSRI = Selective Serotonin Reuptake Inhibitor; CBT = Cognitive Behavioural Therapy).