Initial Psychiatric Evaluation for Depression
Begin the evaluation by directly assessing depressed mood and anhedonia using two screening questions: "Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?" 1. If positive, immediately quantify severity using the PHQ-9 (Patient Health Questionnaire-9), which scores each of the 9 DSM-IV criteria from 0 (not at all) to 3 (nearly every day) 2, 3.
Severity Classification and Treatment Threshold
- PHQ-9 scores of 5,10,15, and 20 represent mild, moderate, moderately severe, and severe depression respectively 3
- A PHQ-9 score ≥10 indicates moderate to severe depression requiring treatment 2
- For mild depression (PHQ-9 5-9), initiate cognitive behavioral therapy (CBT) alone as first-line treatment, avoiding antidepressants since drug-placebo differences are virtually nonexistent in this population 4
- For moderate to severe depression (PHQ-9 ≥10), initiate combined treatment with a second-generation antidepressant and CBT, as combination therapy is superior to monotherapy 2, 4
Critical Safety Assessment (Mandatory at Every Visit)
Directly assess suicidal risk by asking about thoughts of death or suicidal ideation, including prior attempts, plans, methods, intent, and potential lethality 1, 2. This evaluation is obligatory and must be performed at each consultation 2.
Additional safety elements to assess:
- Prior or current aggressive ideas including thoughts of physical or sexual aggression or homicide 1
- Prior aggressive behaviors (homicide, domestic violence, workplace violence) 1
- Prior intentional self-injury without suicidal intent 1
- Current or recent substance use disorder or changes in alcohol/substance use 1
Comprehensive Psychiatric History
Document all past and current psychiatric diagnoses, prior psychotic symptoms, and complete treatment history including type, duration, doses, response, and adherence to past treatments 1.
Specific elements to obtain:
- History of psychiatric hospitalization and emergency department visits 1
- Psychiatric review of systems including anxiety symptoms, panic attacks, and sleep abnormalities (including sleep apnea) 1
- Assessment of impulsivity 1
Medical History and Comorbidities
Assess all current medications (prescribed, over-the-counter, herbal supplements, vitamins) and their side effects, as well as allergies and drug sensitivities 1.
Critical medical elements:
- Determine if the patient has an ongoing relationship with a primary care provider 1
- Document past or current medical illnesses, hospitalizations, surgeries, and complementary treatments 1
- Assess for neurological or neurocognitive disorders, physical trauma including head injuries 1
- Evaluate cardiopulmonary status, endocrinological disease, and infectious diseases (HIV, hepatitis C, sexually transmitted diseases) 1
- Obtain sexual and reproductive history 1
Functional Impairment Assessment
Evaluate the impact of depression on work performance, family relationships, social activities, and self-care capacity 2. This assessment is crucial for determining treatment intensity and monitoring response 2.
Screening for Bipolar Disorder (Critical Pitfall to Avoid)
Before initiating antidepressant treatment, conduct detailed screening for bipolar disorder risk, including detailed psychiatric history and family history of suicide, bipolar disorder, and depression 5, 6. Treating a manic episode with an antidepressant alone may precipitate a mixed/manic episode in at-risk patients 5, 6.
Substance Use Assessment
Document the patient's use of tobacco, alcohol, marijuana, cocaine, heroin, hallucinogens, and any misuse of prescribed or over-the-counter medications or supplements 1.
Initial Treatment Selection Based on Severity
For Mild Depression (PHQ-9 5-9):
- Start CBT alone; do not prescribe antidepressants 4
For Moderate to Severe Depression (PHQ-9 ≥10):
- Initiate sertraline 50-200 mg/day as the preferred antidepressant due to favorable side effect profile 2
- Alternative options include escitalopram or fluoxetine with similar efficacy 2
- Simultaneously refer for CBT 2, 4
- Selection should be based on side effect profile, cost, and patient preferences 1, 2
Early Monitoring Protocol (Critical for Safety)
Evaluate the patient within 1-2 weeks of starting treatment to monitor for emergent suicidal ideation, agitation, or unusual behavioral changes 2, 4, 5. This early follow-up is obligatory 2.
At the 1-2 week visit:
- Assess for early adverse effects (nausea, headache, insomnia) 2
- Reinforce adherence and educate about response latency (4-6 weeks for therapeutic effect) 2
- Monitor for anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, or mania 5, 6
Ongoing Monitoring and Response Assessment
Reassess biweekly or monthly until symptoms remit, evaluating compliance with both pharmacological and psychological treatments 1.
- After 6-8 weeks of treatment at therapeutic doses, if there is no adequate improvement, modify treatment through dose adjustment, switching agents, or adding augmentation strategies 2, 4
- Use PHQ-9 scores pre- and post-treatment to gauge efficacy and monitor adherence 1
Second-Line Strategies for Inadequate Response
If no improvement after 6-8 weeks at therapeutic doses, consider augmentation with quetiapine or aripiprazole (monitoring metabolic effects including weight gain, lipid changes, glucose) or adding CBT 2.
Treatment Duration
- Continuation phase: maintain treatment for 4-9 months after achieving satisfactory response 1, 2
- Maintenance phase: patients with ≥2 previous episodes should continue treatment for ≥1 year 1, 2
Immediate Referral to Psychiatry
Refer immediately if there is significant suicidal risk, psychotic symptoms, suspected bipolar disorder, lack of response to 2 adequate antidepressant trials, or severe depression with marked functional impairment 2.