History of Present Illness (HPI)
Chief Complaint: Depression for more than two weeks
History of Present Illness:
The patient presents with a greater than two-week history of persistent depressive symptoms meeting criteria for major depressive disorder. The patient reports pervasive low mood present most of the day, nearly every day, accompanied by marked anhedonia (loss of interest or pleasure in activities) severe enough to cause inability to get out of bed 1. Associated neurovegetative symptoms include appetite changes (either increased or decreased intake) and sleep disturbance (insomnia or hypersomnia) 1, 2. The patient denies suicidal ideation, homicidal ideation, auditory hallucinations, or visual hallucinations 3. Functional impairment is significant, as evidenced by the inability to perform basic daily activities such as getting out of bed 1.
Pertinent Positives:
- Depressed mood for >2 weeks 1
- Anhedonia (loss of interest/pleasure) 3
- Inability to get out of bed (severe functional impairment) 1
- Appetite changes 1
- Sleep disturbance 1
Pertinent Negatives:
- No suicidal ideation or plan 3
- No homicidal ideation 3
- No auditory or visual hallucinations 3
- No psychotic features 3
Risk Assessment:
- Suicide risk: Currently denies suicidal ideation; however, this requires ongoing monitoring as risk can emerge during treatment 3, 1
- Psychosis: Absent 3
- Substance use: Must be assessed for comorbid substance use disorders 1
- Anxiety: Must be screened, as 50-60% of patients with depression have comorbid anxiety 1
Plan of Care and Treatment
Immediate Assessment and Diagnostic Confirmation
Confirm the diagnosis using DSM-5 criteria and assess severity:
The patient meets criteria for major depressive disorder with at least 5 symptoms present for ≥2 weeks (depressed mood, anhedonia, sleep disturbance, appetite changes, and inability to function), with at least one core symptom being depressed mood or anhedonia 1, 2.
Administer the PHQ-9 to quantify symptom severity; a score ≥8 indicates clinically significant depression requiring intervention 1, 3.
Assess for comorbid conditions:
Evaluate functional impairment across work/school, home, and social domains 1.
Perform immediate suicide risk assessment at every visit, documenting any plan, intent, recent attempts, or family history of suicide or bipolar disorder 1.
Severity Classification and Treatment Selection
Based on the presenting symptoms (inability to get out of bed, multiple neurovegetative symptoms), this patient has moderate to severe major depressive disorder 1.
For Moderate to Severe Depression:
Initiate combination therapy with both a second-generation antidepressant (SSRI or SNRI) AND cognitive-behavioral therapy (CBT) concurrently, as this approach nearly doubles remission rates (57% vs 31% with medication alone) 1, 4.
Pharmacotherapy
Start a second-generation antidepressant at the FDA-approved starting dose:
First-line options include:
Selection criteria:
For patients with comorbid chronic pain, consider an SNRI (duloxetine or venlafaxine) as these achieve higher remission rates (49% vs 42% with SSRIs) 1.
Psychotherapy
Initiate cognitive-behavioral therapy (CBT) concurrently with pharmacotherapy, not sequentially 1, 4.
- Alternative evidence-based psychotherapies include:
Safety Planning (Mandatory)
Develop a written safety plan at the initial visit that includes:
- Limiting access to lethal means (firearms, medications, sharp objects) 1
- Identifying a responsible third party for monitoring 1
- Establishing an emergency communication protocol (crisis hotline numbers, emergency contact) 1
Explicitly discuss limits of confidentiality with the patient and support network 1.
Monitoring Schedule
Week 1-2 (Critical Early Monitoring Period):
Conduct a mandatory assessment within 1-2 weeks of treatment initiation to evaluate:
- Emergence of suicidal thoughts, plans, or behaviors (suicide risk peaks during the first 1-2 months of treatment) 1
- Agitation, irritability, or unusual behavioral changes 1
- Early adverse effects (nausea, headache, sexual dysfunction) 1
- Medication adherence 1
Week 4:
Assess treatment response using the PHQ-9 1.
Week 6-8:
If symptom reduction is <50% on the PHQ-9, modify the treatment plan by:
- Dose escalation to the maximum FDA-approved dose 1
- Switching to a different antidepressant class 1
- Adding augmentation (buspirone or bupropion SR) 1
- Intensifying CBT 1
Treatment Duration
Continue antidepressant therapy for 4-9 months after achieving remission to reduce relapse risk 1, 3.
For patients with recurrent depression (≥2 prior episodes), maintain treatment for at least 1 year or longer 1.
Additional Interventions
Consider bright light therapy (10,000 lux for 30 minutes each morning) as an adjunct, which is effective for mild to moderate depression regardless of seasonal pattern 1.
Recommend supervised aerobic exercise, which achieves remission outcomes comparable to sertraline with lower discontinuation rates due to adverse events 1.
Common Pitfalls to Avoid
Do not use tricyclic antidepressants as first-line agents due to higher adverse-effect profiles and greater overdose risk 1.
Do not discontinue treatment prematurely; therapeutic effects typically require 4-6 weeks 1.
Do not assume treatment resistance without confirming adequate dose (maximum FDA-approved), duration (≥4 weeks), and adherence (consider plasma level testing if uncertain) 1.
Do not overlook non-adherence, which affects up to 50% of patients and can masquerade as treatment resistance 1.
Recognize that approximately 63% of patients experience at least one adverse effect, most of which are transient; continued monitoring is essential rather than premature discontinuation 1.
Referral Criteria
Refer to psychiatry or mental health specialist if: