A 34-year-old woman presents to the clinic with a 6-week history of profound sadness, anhedonia, and terminal insomnia. She reports significant functional impairment, having recently taken a leave of absence from her job due to a severe inability to concentrate. Review of systems is notable for a 4.5-kg (10-lb) weight loss and mild psychomotor agitation. Thorough psychiatric screening confirms the absence of any past manic or hypomanic episodes, ruling out bipolar disorder. Over the next 14 months, her major depressive disorder exhibits a complex trajectory, requiring a progressive, stepped-care escalation of her management plan according to standard psychiatric guidelines. Arrange the following clinical interventions in the most appropriate chronological sequence, beginning with her initial presentation and escalating to the management of life-threatening psychiatric complications.
- 1Initiate pharmacotherapy with a first-line selective serotonin reuptake inhibitor (e.g., sertraline) alongside psychoeducation.
- 2Titrate the initial selective serotonin reuptake inhibitor (SSRI) to its maximum tolerated therapeutic dose due to an inadequate clinical response at 6 weeks.
- 3Cross-titrate to an antidepressant with a different mechanism of action (e.g., a serotonin-norepinephrine reuptake inhibitor) after a complete lack of response to an optimized medication trial.
- 4Augment the current regimen with a second-generation antipsychotic (e.g., aripiprazole) or lithium to address a partial response to therapy.
- 5Proceed with electroconvulsive therapy (ECT) following the acute onset of food refusal, severe psychomotor retardation, and active suicidal intent with a specific plan.