How should I evaluate and treat a 29-year-old woman with a one-year history of major depressive symptoms, low energy, anhedonia, difficulty getting out of bed, feeling lazy, on escitalopram 5 mg daily, and impulsive sexual behavior?

Evaluation and Management of Treatment-Resistant Depression with Impulsive Behavior

This patient requires immediate dose escalation of escitalopram to at least 10-20 mg daily, combined with structured cognitive behavioral therapy focusing on behavioral activation, plus comprehensive assessment for bipolar disorder and personality disorders given the combination of persistent anhedonia, sexual impulsivity, and inadequate response to subtherapeutic antidepressant dosing. 1, 2

Critical Initial Assessment

Safety Evaluation

• Assess for suicidal ideation immediately using PHQ-9 item 9, as any endorsement requires emergency psychiatric evaluation regardless of other symptoms 1, 3
• Evaluate for risk of harm to self or others, which mandates immediate referral for emergency evaluation by a licensed mental health professional 1

Diagnostic Clarification

• Complete full PHQ-9 assessment to quantify depression severity; her symptoms of anhedonia ("no fun things"), anergia ("lazy, can't come out of bed"), and one-year duration suggest moderate to severe depression (likely PHQ-9 ≥15) 1, 3
• Screen specifically for bipolar disorder given the sexual recklessness, as impulsive hypersexuality may represent hypomanic/manic episodes rather than pure impulsivity; missing bipolar disorder leads to antidepressant monotherapy worsening mood cycling 1
• Evaluate for personality disorders (particularly borderline personality disorder) given chronic impulsive sexual behavior, as this fundamentally changes treatment approach and prognosis 1
• Assess duration and pattern of sexual impulsivity: does it occur during distinct mood episodes or is it chronic baseline behavior? 1

Pharmacologic Management

Immediate Medication Adjustment

• Escitalopram 5 mg daily is subtherapeutic; the FDA-approved and evidence-based dosing range is 10-20 mg daily for major depressive disorder 4, 2
• Increase to escitalopram 10 mg daily immediately, with plan to titrate to 20 mg daily if inadequate response after 2-4 weeks 2, 5
• Escitalopram demonstrates dose-dependent efficacy, with 20 mg showing superior outcomes in moderate to severe depression 2, 5

Monitoring and Expected Timeline

• Monitor for response at 2-4 weeks; escitalopram demonstrates relatively rapid onset of antidepressant action compared to other SSRIs 2, 5
• Common pitfall: Anhedonia specifically may remain resistant to SSRI treatment even when other depressive symptoms improve; one study showed escitalopram failed to normalize hedonic capacity despite treating other MDD symptoms 6
• If anhedonia persists despite dose optimization and improvement in other symptoms, consider augmentation with bupropion (which has dopaminergic activity targeting reward pathways) or switching to an SNRI like venlafaxine 1, 4

Psychological Interventions

High-Intensity Structured Therapy

• Refer immediately for individual cognitive behavioral therapy (CBT) delivered by a licensed mental health professional, as her PHQ-9 score likely indicates moderate to severe symptomatology requiring high-intensity intervention 1
• CBT should specifically incorporate behavioral activation (directly targeting anergia and anhedonia), cognitive restructuring, and problem-solving strategies 1
• Behavioral activation is particularly effective for the "can't get out of bed" presentation, using structured activity scheduling to break the inertia-depression cycle 1, 7

Addressing Impulsive Sexual Behavior

• If sexual impulsivity is part of depressive syndrome (seeking connection/validation during depressive episode), CBT addressing underlying depression should help 1
• If sexual impulsivity represents separate impulse control issue or personality pathology, dialectical behavior therapy (DBT) or specialized impulse control interventions are indicated 1

Diagnostic Workup for Comorbidities

Rule Out Medical Causes

• Thyroid function tests (TSH, free T4) to exclude hypothyroidism mimicking or exacerbating depression 1
• Complete blood count and comprehensive metabolic panel to assess for anemia, electrolyte abnormalities, or renal/hepatic dysfunction 1
• Vitamin B12 and vitamin D levels, as deficiencies contribute to fatigue and mood symptoms 1

Psychiatric Comorbidity Assessment

• Formal structured assessment for bipolar I/II disorder using mood disorder questionnaire or clinical interview focusing on lifetime history of elevated/irritable mood, decreased need for sleep, increased goal-directed activity, or excessive involvement in pleasurable activities with high potential for painful consequences 1
• Screen for anxiety disorders, as these commonly co-occur with MDD and influence treatment selection 1
• Assess for substance use disorders, particularly given impulsive sexual behavior pattern 1

Treatment Algorithm Based on Severity

If PHQ-9 Score 8-14 (Moderate Depression)

• Increase escitalopram to therapeutic dose (10-20 mg) 2, 5
• Initiate low-intensity CBT with behavioral activation and structured physical activity program 1, 7
• Seek consultation with psychology or psychiatry for diagnostic confirmation 1

If PHQ-9 Score ≥15 (Moderate-Severe to Severe Depression)

• Immediate referral to psychiatry for diagnosis and treatment 1, 3
• Increase escitalopram to 10 mg immediately with plan for 20 mg 2, 5
• High-intensity individual psychotherapy with licensed mental health professional 1
• Consider combination therapy (medication + psychotherapy) from outset, as this is superior to monotherapy in moderate-severe depression 1

Critical Pitfalls to Avoid

• Do not continue subtherapeutic dosing: 5 mg escitalopram is below the therapeutic range and explains treatment failure 2, 5
• Do not miss bipolar disorder: Sexual recklessness may be hypomanic symptom; antidepressant monotherapy in bipolar disorder can precipitate mood cycling or mixed states 1
• Do not underestimate one-year duration: This represents chronic, treatment-resistant depression requiring aggressive intervention, not "watchful waiting" 7, 3
• Do not omit safety assessment: Complete PHQ-9 including self-harm item regardless of patient's apparent emotional state 1, 3
• Do not ignore persistent anhedonia: If anhedonia fails to improve with dose-optimized escitalopram, this requires medication adjustment (augmentation or switch), not continued observation 6

Follow-Up Schedule

• Reassess in 2 weeks after dose increase for tolerability, adherence, and early response 2, 5
• Full efficacy assessment at 4-6 weeks using PHQ-9 to quantify improvement 1, 3
• If <50% reduction in PHQ-9 score by 6-8 weeks, this represents inadequate response requiring medication adjustment (increase to 20 mg if on 10 mg, or switch/augment if already on 20 mg) 1, 2
• Long-term maintenance therapy for at least 4-9 months after achieving remission to prevent relapse, given one-year duration of current episode 1, 4