From Phenotype to Treatment Plan: A Stepwise Clinical Approach to Moderate-Severe Major Depressive Disorder with Suicidal Ideation in High-Functioning Adult Patient

Abstract

Major depressive disorder (MDD) represents a significant public health concern, characterized by high rates of morbidity and functional impairment. This detailed case study provides an in-depth analysis of the assessment, diagnostic formulation, and treatment planning for a 34-year-old female presenting with a classic constellation of depressive symptoms. The patient,  reported a three-month history of persistent dysphoria, pervasive anhedonia, neurovegetative disturbances (insomnia, appetite/weight loss, fatigue), and cognitive impairments, alongside passive suicidal ideation. A standardized assessment protocol, incorporating the Patient Health Questionnaire-9 (PHQ-9) and the Beck Depression Inventory (BDI), confirmed symptoms of moderate to severe intensity. Following a structured clinical interview and risk assessment, a primary diagnosis of MDD, single episode, moderate severity (ICD-10: F32.1) was established, with a comorbid provisional diagnosis of generalized anxiety disorder (GAD). This paper delineates an integrated, biopsychosocial treatment plan formulated for the patient. The intervention strategy synergistically combines pharmacotherapy (initiation of the SSRI sertraline), evidence-based psychotherapy (a 16-week protocol of Cognitive-Behavioral Therapy), and targeted lifestyle modifications. The rationale for each treatment modality is explored within the context of current clinical guidelines and the patient’s specific presentation. Explicit short-term (1-2 month) and long-term (3-6 month) therapeutic goals are defined, alongside a structured plan for monitoring, safety management, and psychoeducation. The discussion concludes with a prognostic evaluation, emphasizing that consistent adherence to this multimodal framework is associated with a positive outlook for significant symptom remission and functional recovery, while also highlighting the critical importance of relapse prevention strategies in ensuring sustained mental well-being.