What is the initial workup and treatment for a patient presenting with depression?

Initial Workup and Treatment for Depression

The initial workup for depression should include standardized screening tools, assessment of depressive symptoms based on DSM-5 criteria, evaluation for comorbidities, and development of a treatment plan that includes education, safety planning, and either active monitoring (for mild depression) or immediate treatment (for moderate to severe depression). 1

Initial Assessment and Diagnosis

Screening and Identification

• Use formal depression screening instruments for all patients or targeted screening for high-risk individuals 1
• High-risk factors warranting targeted screening:
  • Previous history of depression
  • Family history of depression, bipolar disorder, or suicide
  • Substance use disorders
  • Significant psychosocial stressors or trauma history
  • Frequent somatic complaints
  • Foster care or adoption 1

Diagnostic Evaluation

1. Symptom Assessment:

   • Evaluate symptoms using DSM-5 diagnostic criteria
   • Use standardized depression tools to aid assessment
   • Look beyond self-reported mood - depression may present as irritability, fatigue, insomnia, weight changes, or academic/work decline 1

2. Severity Assessment:

   • Determine if depression is mild, moderate, or severe
   • Assess functional impairment across domains (home, school/work, social)
   • Evaluate subjective distress 1

3. Comorbidity Screening:

   • Screen for other psychiatric conditions (anxiety, substance use)
   • Rule out medical causes of depressive symptoms
   • Consider medication side effects that may cause depression 2

4. Safety Assessment:

   • Evaluate suicide risk (ideation, plan, intent, access to means)
   • Assess for self-harm behaviors
   • Determine need for immediate intervention 1

Initial Management

For All Patients with Depression

1. Education and Counseling:

   • Educate patient and family about depression causes, symptoms, and treatment options
   • Discuss expected outcomes and timeline for improvement
   • Provide information at an appropriate developmental/educational level 1

2. Safety Planning:

   • Establish emergency communication plan
   • Restrict access to lethal means
   • Engage concerned third parties for support
   • Warn about disinhibiting effects of alcohol and drugs 1

3. Treatment Goal Setting:

   • Develop specific, measurable goals in key functioning areas
   • Create written action plans to improve adherence 1

Treatment Approach Based on Severity

For Mild Depression:

• Consider active support and monitoring before starting medication or formal therapy 1
• Components of active support:
  • Regular follow-up (every 1-2 weeks initially)
  • Psychoeducation and supportive counseling
  • Self-management strategies
  • Monitoring of symptoms and suicidality 1

For Moderate to Severe Depression:

• Immediate treatment initiation is recommended 1
• Treatment options:

  1. Pharmacotherapy:

     • Start with second-generation antidepressants (SSRIs) as first-line 3
     • Initial adult dose: fluoxetine 20mg daily in the morning 4
     • Initial pediatric dose: fluoxetine 10mg daily (can increase to 20mg after 1 week) 4
     • Full effect may take 4+ weeks 4
     • Monitor closely for side effects and suicidality, especially in first 1-2 weeks 3

  2. Psychotherapy:

     • Cognitive behavioral therapy (CBT) is highly effective 3
     • Other effective options: interpersonal therapy, psychodynamic therapies 3

  3. Combination Treatment:

     • For moderate to severe depression, combining medication and psychotherapy may be more effective than either alone 3

Ongoing Management

1. Regular Monitoring:

   • Assess response within 1-2 weeks of starting treatment
   • Monitor for therapeutic response, side effects, and suicidality 3
   • If inadequate response after 6-8 weeks, consider dose adjustment, medication switch, or adding psychotherapy 3

2. Treatment Duration:

   • First episode: continue treatment 4-9 months after achieving remission 3
   • Recurrent depression: consider maintenance treatment for 1+ year 3

3. Collaborative Care:

   • Organize clinical settings to reflect best practices in integrated care models
   • Facilitate contact with psychiatrists, case managers, or embedded therapists 1
   • Consider mental health consultation for complex cases (severe depression, comorbidities) 1

Common Pitfalls to Avoid

1. Inadequate Diagnosis:

   • Failing to use standardized tools or diagnostic criteria
   • Missing comorbid conditions that complicate treatment 5

2. Insufficient Monitoring:

   • Not following up soon enough after treatment initiation
   • Failing to assess for suicidality, especially early in treatment 3

3. Premature Treatment Discontinuation:

   • Stopping medication too soon after symptom improvement
   • Abrupt discontinuation leading to withdrawal symptoms 3

4. Overlooking Psychosocial Factors:

   • Focusing solely on medications without addressing environmental stressors
   • Not involving family/support systems in treatment planning 1