Provide an example of a depression clerking for a 45‑year‑old female with a two‑month history of low mood, anhedonia, insomnia, reduced appetite, low energy, occasional passive suicidal thoughts, hypothyroidism treated with levothyroxine, no other chronic illnesses, social alcohol use, family history of depression, and a normal mental‑state examination.

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Depression Clerking Example for a 45-Year-Old Female

A comprehensive depression clerking for this patient should systematically document presenting symptoms, assess severity using validated tools, rule out organic causes (particularly thyroid dysfunction), evaluate suicide risk, and formulate a treatment plan based on symptom severity.

Presenting Complaint

  • Low mood and loss of interest in activities for 2 months

History of Presenting Complaint

Core Depressive Symptoms (Duration: 2 months)

  • Depressed mood: Present most days
  • Anhedonia: Markedly diminished interest or pleasure in activities
  • Sleep disturbance: Insomnia (specify type: initial, middle, or terminal insomnia)
  • Appetite changes: Reduced appetite (document weight loss if present)
  • Energy: Low energy/fatigue nearly every day
  • Concentration: Diminished ability to think or concentrate
  • Suicidal ideation: Passive thoughts ("better off dead") - frequency, specificity, intent, and plan must be documented 1

PHQ-9 Screening

Administer the 2-item PHQ-9 initially 1:

  1. "Little interest or pleasure in doing things" - score
  2. "Feeling down, depressed, or hopeless" - score

If score ≥2 on either item, complete full PHQ-9 (remaining 7 items covering sleep, energy, appetite, self-worth, concentration, psychomotor changes, self-harm thoughts). Use cutoff score of ≥8 (not the traditional ≥10) for cancer/medical populations 1.

Functional Impairment

  • Occupational: Ability to work (currently maintaining work responsibilities)
  • Social: Relationship difficulties (conflict with partner as precipitant)
  • Self-care: Activities of daily living
  • Quality of life impact

Precipitating Factors

  • Relationship conflict with partner (began several months ago)
  • Life stressors or transitions

Associated Symptoms to Document

  • Feelings of worthlessness or excessive guilt
  • Psychomotor agitation or retardation (observable)
  • Recurrent thoughts of death beyond suicidal ideation 2

Risk Assessment

Suicide Risk Evaluation (CRITICAL)

If any risk of harm to self or others: immediate referral for emergency psychiatric evaluation; facilitate safe environment; one-to-one observation 1.

Document:

  • Current suicidal ideation: Passive thoughts present ("better off dead")
    • Frequency: Occasional
    • Intent: None vs. present
    • Plan: Specific vs. none
    • Access to means: Firearms, medications
  • Prior suicide attempts: None documented
  • Risk factors for completed suicide 3:
    • Age: 45 years (moderate risk)
    • Gender: Female (lower risk than males)
    • Mental state: Depressed
    • Substance use: Social alcohol only
    • Living situation: With partner vs. alone
    • Family history of suicide

Risk Factors for Depression

  • Family history: Positive for depression (first-degree relatives)
  • Chronic medical illness: Hypothyroidism (treated)
  • Substance use: Social alcohol (quantify: drinks per week)
  • Prior psychiatric history
  • Social support: Assess coping skills and available support 1

Past Psychiatric History

  • Previous episodes of depression
  • Previous psychiatric hospitalizations
  • Previous suicide attempts or self-harm
  • Previous psychiatric treatments (medications, psychotherapy)

Medical History

Current Medical Conditions

  • Hypothyroidism: Treated with levothyroxine
    • Current dose
    • Duration of treatment
    • Last TSH level and date
    • Compliance with medication
    • Critical: Hypothyroidism is a known cause of treatment-resistant depression and must be adequately treated 4

Medication Review

  • Levothyroxine: Dose and compliance
  • Drug interactions: Levothyroxine may interact with antidepressants (particularly sertraline may increase levothyroxine requirements; tricyclics may have increased effects) 5
  • Other medications that may affect mood

Review of Systems

  • Thyroid symptoms: Cold intolerance, weight changes, constipation, dry skin
  • Cardiovascular: Palpitations, chest pain
  • Neurological: Headaches, tremor, weakness

Substance Use History

  • Alcohol: Social use (quantify frequency and amount)
  • Tobacco
  • Illicit drugs
  • Caffeine

Family History

  • Depression: Positive (specify which relatives)
  • Other psychiatric disorders
  • Suicide
  • Thyroid disease

Social History

  • Living situation: With partner
  • Occupation and work status
  • Financial stressors
  • Social support network
  • Recent life changes or stressors

Mental State Examination

Appearance and Behavior

  • Grooming and hygiene
  • Eye contact
  • Psychomotor activity: Normal vs. retardation vs. agitation

Speech

  • Rate, rhythm, volume, tone

Mood and Affect

  • Mood: "Sad" (patient's subjective description)
  • Affect: Congruent, range (restricted vs. full), intensity

Thought Process

  • Linear, goal-directed vs. tangential, circumstantial

Thought Content

  • Suicidal ideation: Passive thoughts present, no intent or plan
  • Homicidal ideation: Denied
  • Delusions: None
  • Obsessions: None

Perception

  • Hallucinations: None
  • Illusions: None

Cognition

  • Orientation: Alert and oriented to person, place, time
  • Attention/concentration: Impaired (consistent with depression)
  • Memory: Assess if indicated

Insight and Judgment

  • Insight: Recognizes symptoms, attributes to relationship stress
  • Judgment: Intact (continuing work and responsibilities)

Physical Examination

  • Vital signs
  • Thyroid examination: Size, nodules, tenderness
  • Cardiovascular examination
  • Neurological examination if indicated

Investigations

Laboratory Tests

Essential to rule out organic causes and assess thyroid status:

  • TSH and free T4: To confirm adequate thyroid replacement 5, 4
  • Complete blood count
  • Comprehensive metabolic panel
  • Vitamin B12 and folate
  • Consider: Vitamin D, screening for other endocrine disorders if clinically indicated

Formulation

Diagnosis

Major Depressive Disorder - meets criteria with ≥5 symptoms over 2 months including depressed mood and anhedonia, causing functional impairment 2, 6.

Severity Assessment

Based on PHQ-9 score 1:

  • Score 1-7: Minimal/mild - monitor, supportive care
  • Score 8-14: Moderate - consider psychology/psychiatry consultation
  • Score 15-19: Moderately severe - refer to psychology/psychiatry
  • Score 20-27: Severe - urgent psychiatric referral

Contributing Factors

  • Relationship conflict (precipitant)
  • Hypothyroidism (ensure adequately treated)
  • Family history of depression
  • Possible inadequate social support

Management Plan

Immediate Actions

  1. Suicide risk management: Given passive suicidal thoughts, assess need for safety planning; remove access to lethal means (firearms, excess medications) 3
  2. Optimize thyroid treatment: Verify TSH is within target range; inadequately treated hypothyroidism can cause treatment-resistant depression 4

Treatment Based on Severity 1

For Moderate Symptoms (PHQ-9 8-14):

  • Seek consultation with psychology or psychiatry for diagnosis confirmation
  • Low-intensity interventions:
    • Individually guided self-help based on cognitive behavioral therapy
    • Structured physical activity program
    • Psychosocial interventions (group)
    • Consider pharmacotherapy

For Moderate-Severe to Severe Symptoms (PHQ-9 ≥15):

  • Immediate referral to psychology and/or psychiatry
  • High-intensity psychological interventions: Individual therapy by licensed mental health professional (CBT, behavioral activation)
  • Pharmacological treatment 7:
    • Second-generation antidepressants (SSRIs, SNRIs) based on side effect profile, cost, patient preference
    • Important: Levothyroxine may interact with antidepressants; sertraline may increase levothyroxine requirements 5
    • Monitor response within 1-2 weeks of initiation
    • Modify treatment if inadequate response at 6-8 weeks
    • Continue for 4-9 months after satisfactory response (longer for recurrent episodes) 7

Follow-Up

  • Initial: Within 1-2 weeks to assess treatment response and adverse effects 7
  • Regular monitoring: PHQ-9 scores, clinical status, medication adherence
  • TSH monitoring: Especially if starting antidepressants (potential interaction) 5
  • Reassess suicide risk at each visit

Patient Education

  • Nature of depression and expected course
  • Treatment options and rationale
  • Importance of medication adherence (both levothyroxine and antidepressants)
  • Warning signs requiring urgent evaluation
  • Avoid alcohol (can worsen depression and interact with medications)

Safety Planning

  • Emergency contact numbers
  • Remove firearms and excess medications from home 3
  • Identify supportive persons to contact in crisis
  • 24-hour crisis hotline information

This clerking systematically addresses the diagnostic criteria for major depressive disorder 2, 6, incorporates validated screening tools 1, evaluates critical suicide risk 1, 3, considers the important interaction between hypothyroidism and depression 4, and provides a severity-based treatment algorithm 1, 7.

References

3
Guideline

summary of the practice parameters for the assessment and treatment of children and adolescents with suicidal behavior.

Journal of the American Academy of Child and Adolescent Psychiatry, 2001

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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