Impression Statement for Depression
For a patient meeting criteria for a major depressive episode of moderate severity without psychotic features, bipolar spectrum signs, or significant substance use, document: "Major Depressive Disorder, single episode, moderate severity, without psychotic features."
Diagnostic Documentation Framework
The impression statement should capture four essential elements based on DSM-5 criteria:
1. Primary Diagnosis
- State "Major Depressive Disorder" as the principal diagnosis
- This patient meets the required threshold of ≥5 symptoms including the mandatory presence of either depressed mood or anhedonia, plus additional symptoms (fatigue, concentration difficulties, sleep disturbance) lasting >2 weeks with functional impairment 1
2. Episode Specification
- Document as "single episode" since no prior antidepressant trials are mentioned, suggesting this is the first recognized episode
- If there is history of prior episodes, specify "recurrent" instead, as this has significant treatment duration implications 2
3. Severity Designation
- Specify "moderate severity" as stated in the clinical scenario
- Moderate depression typically presents with the depressed mood criterion accompanied by somatic symptoms (fatigue, sleep disturbance, concentration difficulties), distinguishing it from severe depression which more commonly presents with anhedonia and non-somatic symptoms 3
4. Psychotic Features Status
- Explicitly state "without psychotic features" to clarify the absence of delusions or hallucinations
- This distinction is critical for treatment selection, as severe depression with psychotic features may require antidepressant-antipsychotic combination therapy 4
Additional Documentation Considerations
Rule Out Bipolar Spectrum
While the scenario states no bipolar spectrum signs are present, your documentation should reflect that this was actively assessed. The absence of:
- Prior manic or hypomanic episodes
- Family history of bipolar disorder
- Psychomotor agitation or mood lability
This is crucial because misdiagnosis of bipolar disorder as unipolar depression occurs frequently and leads to inappropriate antidepressant monotherapy, which has little efficacy in bipolar depression 5, 6. Approximately 75% of symptomatic time in bipolar disorder consists of depressive episodes, making initial presentation indistinguishable from MDD 6.
Substance Use Exclusion
Document that symptoms are not attributable to substance use or general medical conditions (e.g., hypothyroidism), as required by diagnostic criteria 1.
Functional Impairment
Note the presence of functional impairment in social, occupational, or other important areas, as this distinguishes clinically significant depression from subsyndromal symptoms 7.
Treatment Implications of This Impression
This specific impression statement directly guides evidence-based treatment:
- First episode, moderate severity → Initiate second-generation antidepressant selected based on adverse effect profile, cost, and patient preference (all SGAs have equivalent efficacy) 2
- Treatment duration → Continue for 4-9 months after achieving remission for first episode 2
- Monitoring schedule → Assess within 1-2 weeks of initiation for suicidality, then regularly for therapeutic response 2
- Response timeline → Modify treatment if inadequate response by 6-8 weeks 2
Common Pitfall to Avoid
Do not document simply as "depression" or "depressive symptoms" without specifying episode type and severity. The distinction between first episode versus recurrent depression changes treatment duration recommendations from 4-9 months to potentially years or lifelong therapy 2. Similarly, severity classification affects whether psychotherapy alone, medication alone, or combination therapy is most appropriate 4.