From the Guidelines
Medication for depressive symptoms should be considered when a patient exhibits at least five of the nine SIG E CAPS symptoms for at least two weeks, with one symptom being either depressed mood or anhedonia (loss of interest/pleasure). The SIG E CAPS symptoms include Sleep disturbance, Interest decline, Guilt feelings, Energy loss, Concentration difficulties, Appetite changes, Psychomotor changes, and Suicidal thoughts.
Key Considerations
- First-line pharmacotherapy typically includes selective serotonin reuptake inhibitors (SSRIs) such as sertraline (50-200 mg daily), escitalopram (10-20 mg daily), or fluoxetine (20-80 mg daily) 1.
- Treatment should continue for at least 6-12 months after symptom resolution to prevent relapse.
- For patients with moderate to severe depression, combining medication with psychotherapy often yields better outcomes than either treatment alone.
- If the initial SSRI is ineffective after 4-6 weeks at an adequate dose, consider switching to another SSRI or a different class like SNRIs (venlafaxine, duloxetine) or bupropion.
- Medication choice should be guided by symptom profile, side effect concerns, and patient preference, as recommended by the American College of Physicians 1.
Monitoring and Follow-up
- Clinicians should assess patient status, therapeutic response, and adverse effects of antidepressant therapy on a regular basis beginning within 1 to 2 weeks of initiation of therapy 1.
- Patients should be monitored for the emergence of agitation, irritability, or unusual changes in behavior, as these symptoms can indicate that the depression is getting worse.
- The risk for suicide attempts is greater during the first 1 to 2 months of treatment, and patients should be closely monitored during this period 1.
From the FDA Drug Label
A major depressive episode (DSM–IV) implies a prominent and relatively persistent (nearly every day for at least 2 weeks) depressed or dysphoric mood that usually interferes with daily functioning, and includes at least 5 of the following 9 symptoms: depressed mood, loss of interest in usual activities, significant change in weight and/or appetite, insomnia or hypersomnia, psychomotor agitation or retardation, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, a suicide attempt or suicidal ideation. A major depressive episode implies a prominent and relatively persistent depressed or dysphoric mood that usually interferes with daily functioning (nearly every day for at least 2 weeks); it should include at least 4 of the following 8 symptoms: change in appetite, change in sleep, psychomotor agitation or retardation, loss of interest in usual activities or decrease in sexual drive, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, and a suicide attempt or suicidal ideation.
SIG E CAPS is a mnemonic used to remember the symptoms of depression, which are:
- S - Sleep changes (insomnia or hypersomnia)
- I - Interest (loss of interest in usual activities)
- G - Guilt (feelings of guilt or worthlessness)
- E - Energy (increased fatigue)
- C - Concentration (slowed thinking or impaired concentration)
- A - Appetite (significant change in weight and/or appetite)
- P - Psychomotor (psychomotor agitation or retardation)
- S - Suicidality (suicide attempt or suicidal ideation)
Considering the SIG E CAPS mnemonic, medication for a patient with depressive symptoms should be considered when at least 5 of these symptoms are present, as indicated in the DSM-IV criteria for a major depressive episode 2, 2. Additionally, the patient's symptoms should be prominent and relatively persistent, interfering with daily functioning for at least 2 weeks 2, 3.
From the Research
SIG E CAPS Mnemonic and Depressive Symptoms
The SIG E CAPS mnemonic is a tool used to assess depressive symptoms, with each letter representing a symptom:
- S: Sleep disturbance
- I: Loss of interest
- G: Guilt or worthlessness
- E: Energy loss
- C: Concentration difficulty
- A: Appetite change
- P: Psychomotor agitation or retardation
- S: Suicidal thoughts
Considerations for Medication
When considering giving medication for a patient with depressive symptoms based on the SIG E CAPS mnemonic, the following points are relevant:
- The presence of suicidal thoughts (S) is a critical factor in determining the need for medication, as it indicates a high risk of harm to the patient 4, 5, 6
- Sleep disturbance (S), loss of interest (I), and energy loss (E) are common symptoms of depression that may respond to medication 7
- Guilt or worthlessness (G) and concentration difficulty (C) may also be addressed with medication, particularly selective serotonin reuptake inhibitors (SSRIs) 8, 7
- Appetite change (A) and psychomotor agitation or retardation (P) may be related to the underlying depressive disorder and may improve with treatment 7
Medication Options
SSRIs are commonly used to treat depressive symptoms, and the available evidence suggests that they are effective in reducing symptoms and improving outcomes 5, 8, 7, 6
- Escitalopram has been shown to be particularly effective in terms of response rate, remission rate, and withdrawal rate 7
- Other SSRIs, such as fluoxetine, citalopram, sertraline, paroxetine, and fluvoxamine, may also be effective, but the evidence is less clear 7
Risk of Suicidal Behavior
The risk of suicidal behavior is a critical consideration when prescribing medication for depressive symptoms, particularly in children and adolescents 6