Outpatient / Psychiatry


Last Updated: 3/6/2023

#Depression - PHQ-9 ***


-- PHQ-2: *** in last month felt either down/depressed/hopeless or Little interest/pleasure in doing things

-- PHQ-9: *** 

-- Onset: ***

-- Depression Symptoms: *** over same 2-week span and cause impairment/distress - weight/appetite change, sleep changes, psychomotor agitation/slowing, fatigue, worthlessness/guilt, poor concentration, thoughts of death or SI

-- SI/HI: *** 

-- Other Symptoms: *** mania, anxiety, psychosis


-- Rule out an organic cause of similar symptoms - CBC (anemia), TSH (hypothyroidism)

-- Therapy: *** CBT, talk therapy

-- Medication: *** (most commonly escitalopram 5mg, setraline 25mg, duloxetine 20mg due to fewer side effects)

-- Lifestyle: *** (exercise, nutrition, sleep hygiene, social supports, stress reduction)

-- Refer: to psych if c/f bipolar disease, failure after 2 adequate SSRI trials, severe MDD with SI/HI, psychosis, catatonia features

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Pharmacology of Depression

Patient Guidance and Information

Starting SSRI

Based on your symptoms of depression, we will plan to start at the lowest dose and titrate up based on how you are feeling. Most initial side effects will improve over time with continued use. For this medicine, they may include ***.

We usually need at least 6-12 weeks at a full tolerable dose to assess if it is working or not for your mood. There are plenty of other options for us to try in the event that this medication does not seem to help. It's also important to recognize that in the future we can always trial weaning the medication off, even if it does seem to help.

If You Remember Nothing Else

Screen all patients with PHQ-2 (down/depressed and little interest in activities), and if they screen positive have them fill out PHQ-9 themselves. Though always a shared decision, in mild cases, therapy and CBT alone can be effective. In moderate-severe cases you can discuss initiating a medicine earlier. In general, start with escitalopram or sertraline - they tend to be more efficacious and have better tolerability profiles. Start low and titrate the medicine every 1-2 weeks based on side effect profile, noting that it will usually take at least 6 weeks for most medicines to see an effect. Be mindful of discontinuation syndrome in paroxetine and venlafaxine. In general, if patient is in remission of MDD, continue for 4-9 months. If they have had 3 or more episodes of MDD or a prior severe episode (SI or psychosis) continue for at least 1-3 years. When tapering, do so over 6-8 weeks to decrease risk of relapse and prevent discontinuation syndrome.

Clinical Pearls

  • Major Depressive Disorder is estimated to have a prevalence of 9% in the U.S; diagnosed based on specific criteria and present for at least 2 weeks
  • You can have depressive disorder that is not specifically MDD - due to a general medical condition like cancer, stroke, dementia, substance use like marijuana and alcohol, etc. 
  • Adjustment disorder - symptoms last less than 6 months following termination of the stressor
  • Women at higher risk, 3rd-decade peak onset
  • PHQ-2 is 97% sensitive for MDD if one or more are positive 
  • SIGECAPS (sleep disturbance, interest loss/anhedonia, guilt, lack of energy, concentration problems, appetite suppression, psychomotor retardation, suicidal ideation)
  • CBT - the focus is on behavioral and cognitive restructuring to change disruptive thought patterns
  • Meds and therapy together are superior to either alone, but all options are okay
  • Should consider depression as a cause of FTT/weight loss, fatigue, “pseudo” dementia
  • Discontinuation syndrome can happen in 20% of patients on SSRI for 4 weeks or longer who abruptly stop - flu-like sxs, nausea, insomnia, hyperarousal, sensory disturbances
  • Consider polysomnography if c/f underlying sleep disorder

Trials and Literature

  • ANTLER Trial - NEJM 2021 - in those on stable dose of antidepressant who are currently not depressed with >2 prior depressive episodes, discontinuation of antidepressant was associated with 2-fold higher risk of depression relapse
  • Can-SAD - 2006 - Light therapy as effective as fluoxetine for seasonal depression 
  • SADHART - JAMA 2002 - sertraline is a safe treatment for recurrent depression among patients recently hospitalized for ACS

Other Resources