What is the recommended evaluation and treatment plan for an adult female with a history of major depressive disorder (MDD) and generalized anxiety disorder (GAD) who presents with hopelessness, functional withdrawal, increased alcohol consumption, relationship conflict, and possible suicidal thoughts?

Immediate Evaluation and Management of Depression with Increased Alcohol Use and Relationship Conflict

This patient requires immediate suicide risk assessment, followed by structured screening with PHQ-9 and GAD-7, treatment of both depression and problematic alcohol use, and combined individual CBT with couples therapy given the prominent relationship dysfunction. 1, 2, 3

Immediate Safety Assessment

Assess suicide risk immediately at this visit - any patient with hopelessness, anhedonia, and increased alcohol use requires direct questioning about self-harm thoughts. 2, 3

• If ANY suicidal ideation is present: refer for emergency psychiatric evaluation, facilitate safe environment, and initiate one-to-one observation until psychiatric assessment is complete. 4
• The combination of hopelessness, functional withdrawal, and increased alcohol consumption represents high-risk features that mandate this assessment cannot be deferred. 2, 3
• Critical pitfall: Never skip PHQ-9 item 9 (self-harm assessment) - this artificially lowers scores and misses suicide risk. 2

Structured Screening and Diagnosis

Administer both PHQ-9 and GAD-7 at this visit to quantify symptom severity and distinguish between MDD and GAD, which share overlapping symptoms and have 31% comorbidity. 2, 3

PHQ-9 Interpretation:

• Score ≥8 indicates clinically significant depression requiring intervention. 1, 3
• The patient's presentation (hopelessness, anhedonia, functional withdrawal) suggests moderate-to-severe depression. 3

GAD-7 Interpretation:

• Score ≥5 suggests mild anxiety, ≥10 moderate anxiety, ≥15 severe anxiety. 4, 2
• GAD patients may present with "concerns" or "worries" rather than overt anxiety symptoms. 4, 2

Essential Laboratory Workup:

Before finalizing the diagnosis, obtain: thyroid function tests, complete metabolic panel, complete blood count, vitamin B12, folate levels, and toxicology screen to rule out medical causes. 2

Alcohol Use Assessment and Management

The increased alcohol consumption requires concurrent evaluation and treatment - substance use disorders significantly complicate anxiety/depression management and must be addressed simultaneously. 2

• Screen for alcohol use disorder using validated tools (AUDIT-C or full AUDIT). 2
• Critical pitfall: Missing substance use disorders leads to treatment failure in depression/anxiety management. 2
• Alcohol withdrawal risk must be assessed before initiating treatment. 2

Treatment Algorithm

For Moderate-to-Severe Depression with Relationship Conflict:

Implement combined approach using both individual CBT and behavioral couples therapy as the primary intervention. 1

Individual CBT Components:

• Focus on identifying and challenging negative thought patterns related to self, relationship, and future. 1
• Include behavioral activation to increase engagement in pleasurable activities (directly addresses "hobbies don't appeal to her"). 1, 3
• Develop stress reduction and coping strategies. 1
• Sessions should be structured with relevant treatment manuals. 4

Couples Therapy Components:

• Address relationship conflict and arguments with boyfriend directly through behavioral couples therapy. 1
• This is evidence-based specifically for depression with marital/relationship distress. 1

Pharmacotherapy Consideration:

Consider adding antidepressant medication as adjunct treatment for moderate-to-severe depression with relationship distress. 1

• SSRIs are first-line pharmacotherapy. 5
• Important consideration for young adults (18-24 years): Risk of suicidal behavior nearly doubles in first month of SSRI treatment (OR 2.31). 4
• If paroxetine is considered, be aware it has highest odds of nonfatal suicidal behavior (OR 6.70), especially in ages 18-29. 4
• Monitor suicide risk at EVERY visit when initiating or adjusting antidepressants. 2

Treatment Sequencing:

Prioritize depression treatment first - evidence suggests treating depressive symptoms simultaneously improves anxiety symptoms, with depression appearing to be the primary driver in comorbid presentations. 2, 3

• Comorbid anxiety should be treated after depression as usual practice. 3
• Use both PHQ-9 and GAD-7 at each visit to objectively track symptom changes in both domains. 2

Monitoring Schedule

Assess depression symptoms biweekly or monthly until remission. 1, 3

• Continue treatment for at least 4-9 months after initial response (continuation phase). 1, 3
• If no improvement after 8 weeks despite good compliance, alter the treatment approach. 1, 3
• Monitor for treatment adherence and satisfaction with both individual and couples therapy. 1
• Reassess suicide risk at every single visit. 2

Common Pitfalls to Avoid

• Never defer suicide assessment - hopelessness with increased alcohol use is high-risk. 2, 3
• Never treat depression without addressing alcohol use - concurrent substance use requires simultaneous treatment. 2
• Never ignore relationship conflict - this requires specific couples therapy intervention, not just individual treatment. 1
• Never fail to monitor suicide risk monthly when starting antidepressants in young adults. 4, 2
• Never continue ineffective treatment beyond 8 weeks - change approach if no improvement. 1, 3