Major depressive disorder — structured clinical viva

This is recurrent major depression with melancholic features and incomplete response after two adequate antidepressant trials, placing him in an augmentation/specialist pathway with active suicide risk review. First confirm adequacy of prior trials (dose, duration, adherence), exclude bipolarity and substances, and complete medical work-up. Passive death wishes still require full risk assessment and safety planning with the partner as appropriate under privacy law.[4]

Lithium is a legitimate augmenter in unipolar MDD after non-response — not "only for bipolar." STAR*D included lithium versus T3 augmentation after two failed medication treatments. Discuss levels, renal/thyroid monitoring, toxicity education, and teratogenicity if relevant.[1]

ECT has robust efficacy evidence in severe depressive disorders and is appropriate to discuss proactively in severe melancholia with suicide risk and medication non-remission — frame as a medical procedure under anaesthetic with consent covering benefits, cognitive risks, cardiac/anaesthetic risks, and expected course, not as punishment or last-ditch folklore.[2]

After remission, continuation/maintenance antidepressant (and discussion of continuation ECT or lithium if used) is essential because relapse risk is high after multiple episodes; stopping soon after feeling well is a classic error.[3]