Approaching a Patient with Depressive Symptoms in Psychiatry
Immediate Medical Clearance and Safety Assessment
Rule out medical causes of depression first by obtaining TSH, complete blood count, liver function tests, and metabolic panel before initiating psychiatric treatment. 1, 2 Emergency physicians must recognize that behavioral abnormalities can coexist with or be caused by medical disease, particularly delirium masquerading as a psychiatric condition 1.
Critical Safety Screening (Perform Immediately)
- Assess suicidal ideation directly using PHQ-9 item 9—any endorsement of specific plans or intent requires emergency intervention. 2
- Screen for bipolar disorder risk through detailed psychiatric history including family history of bipolar disorder, mania, and suicide 3, 4
- Evaluate for psychotic symptoms (hallucinations, delusions) that would change treatment approach 1
- Assess substance use including alcohol, as this affects treatment selection and can worsen depressive symptoms 1
- Screen for history of sexual, physical, or emotional abuse, as adverse experiences affect symptom perception and treatment response 1
Structured Diagnostic Assessment
Use PHQ-9 for Severity Stratification
Screen with PHQ-2 first (depressed mood and anhedonia questions); if score ≥2, complete full PHQ-9. 2 The PHQ-9 has 89.5% sensitivity and 77.5% specificity at cutoff ≥11 for major depressive disorder 2.
- All positive screens require direct clinical interview using DSM-5 criteria—screening alone does not establish diagnosis. 2 False-positive rates reach 60-76% in primary care settings 2.
- Assess functional impairment across work, relationships, and self-care domains 2
- Obtain collateral information from family members when possible 2
Evaluate Comorbid Conditions
- Screen for anxiety disorders, as 85% of depressed patients have significant anxiety and 90% of anxiety patients have depression. 5
- Assess for eating disorders or disordered eating, which have bidirectional relationships with depression 1
- Evaluate cognitive factors including fatigue, impaired concentration, and memory problems that affect treatment planning 1
- Check for food insecurity using brief screening tools, as this is more common in depression 1
Treatment Algorithm Based on PHQ-9 Score
Mild Depression (PHQ-9: 1-7)
- Provide psychoeducation about depression and normal stress responses 2
- Ensure adequate coping skills and access to resources 2
- Reassess at future visits, particularly for patients with risk factors 2
- Do not initiate antidepressants for mild depressive episodes. 1
Moderate Depression (PHQ-9: 8-14)
Offer choice between evidence-based psychotherapy or antidepressant medication as first-line treatment. 6, 7
Psychotherapy Options (All Have Medium-to-Large Effect Sizes)
- Cognitive therapy (SMD 0.50-0.73) 6
- Behavioral activation 6
- Problem-solving therapy 1, 6
- Interpersonal therapy 1, 6
- Brief psychodynamic therapy 6
- Mindfulness-based psychotherapy 6
Antidepressant Medication Options
Start with SSRIs as first-line pharmacological treatment. 8, 7 Among SSRIs, prefer:
These have favorable side effect profiles and fewer drug interactions 8.
Avoid fluoxetine in older adults due to long half-life. 8 Avoid SSRIs with anticholinergic properties in elderly patients 8.
Alternative first-line options include:
Tricyclic antidepressants or fluoxetine should be considered for moderate to severe depression per WHO guidelines. 1
Moderate-to-Severe/Severe Depression (PHQ-9: 15-27)
Combine psychotherapy with antidepressant medication—this combination shows greater symptom improvement than either treatment alone (SMD 0.30 vs psychotherapy alone, SMD 0.33 vs medication alone). 6
- Make immediate referral to psychology and/or psychiatry for diagnosis and treatment 2
- Assess risk of harm to self or others immediately 2
- Consider collaborative care programs with systematic follow-up, which improve treatment effectiveness (SMD 0.42 vs usual care) 6
Medication Management Specifics
Dosing and Monitoring
- Start antidepressants at low doses and titrate slowly in older adults to minimize side effects. 8
- Evaluate treatment response after 3-4 weeks. 8
- Obtain laboratory tests before each medication adjustment 2
- Monitor for hyponatremia (especially in elderly), liver function changes, and metabolic effects 2
Treatment Duration
Continue antidepressant treatment for 9-12 months after recovery before considering discontinuation. 1 For successful treatment, continue for at least 6 months after significant improvement 8.
Enhanced Monitoring Requirements (FDA Boxed Warnings)
Monitor all patients on antidepressants closely for clinical worsening, suicidality, and unusual behavior changes, especially during initial months and at dose changes. 3, 4
Increased suicidality risk by age group:
- Ages <18: 14 additional cases per 1000 patients 3, 4
- Ages 18-24: 5 additional cases per 1000 patients 3, 4
- Ages 25-64: 1 fewer case per 1000 patients 3, 4
- Ages ≥65: 6 fewer cases per 1000 patients 3, 4
Alert families and caregivers to monitor for agitation, irritability, unusual behavior changes, anxiety, panic attacks, insomnia, hostility, aggressiveness, impulsivity, akathisia, hypomania, and mania. 3, 4
Second-Line Treatment for Non-Response
When initial antidepressant is ineffective, options with approximately equal likelihood of success include 6:
- Switching to different antidepressant medication
- Adding second antidepressant
- Augmenting with non-antidepressant medication
Critical Pitfalls to Avoid
- Never rely on screening scores alone for diagnosis—always confirm with clinical interview using DSM-5 criteria. 2
- Never overlook comorbid anxiety, substance use, or PTSD, as these affect treatment selection and outcomes. 2
- Never prescribe antidepressants for mild depression (PHQ-9 <8) as initial treatment. 1
- Never use benzodiazepines to treat depression—they help anxiety and insomnia but not depressive symptoms and carry dependency risks. 5
- Never use antipsychotics for depression in dementia due to increased mortality risk. 8
- Never abruptly discontinue antidepressants—taper gradually while providing concurrent cognitive behavioral therapy to decrease relapse risk. 4, 7
- Never assume psychiatric presentation is purely psychiatric—always rule out medical causes including thyroid disease, metabolic abnormalities, and delirium. 1, 2
Special Populations
Patients with Dementia
- Implement non-pharmacological interventions (exercise, cognitive stimulation, social engagement) first 8
- For moderate-to-severe depression, add SSRI (citalopram, escitalopram, or sertraline preferred) 8
- Evaluate for pain and other modifiable contributors that may manifest as depression 8
- Avoid tricyclic antidepressants due to anticholinergic effects that worsen cognition 8