A 44-year-old woman presents to her physician for worsening depressive symptoms over the past 6 weeks. She reports anhedonia, diminished concentration, a decrease in her appetite, and difficulty sleeping. She was diagnosed with major depressive disorder two years ago and has been treated with sertraline 50 mg daily which she takes consistently. Vital signs are within normal limits. Physical examination reveals a flat affect and tearfulness during the clinical interview. The Patient Health Questionnaire-9 (PHQ-9) is administered and yields a score of 16. A previously documented score of 8 from three months ago is noted in her chart.
E) Inquire about suicidal ideation
Any patient with acute worsening of previously controlled depressive symptoms should be assessed for suicidal ideation. Failing to inquire about suicidal ideation is a missed opportunity to intervene in a potentially life-threatening situation in this patient with worsening depression. Depression is the leading cause of disability in the United States among individuals aged 15 to 44 years and is a major risk factor for suicide.
The U.S. Preventive Services Task Force (USPSTF) recommends screening all patients for depression. Patients can be screened with validated questionnaires, such as the PHQ-9.
The PHQ-9 score ranges from 0 to 27 (5-9 mild depression, 10-14 moderate depression, 15-19 moderate to severe depression, ≥ 20 severe depression).
Answer choice A: Add aripiprazole, is incorrect. Aripiprazole is a second-generation antipsychotic that has shown benefit as an adjunctive agent for acute treatment of nonpsychotic major depression that does not respond adequately to antidepressant monotherapy. Screening for suicidal ideation is the most important next step in management before medication is added.
Answer choice B: Add brexpiprazole, is incorrect. Brexiprazole is a second-generation antipsychotic that has shown benefit as an adjunctive agent for acute treatment of nonpsychotic major depression that does not respond adequately to antidepressant monotherapy. Screening for suicidal ideation is the most important next step in management before medication is added.
Answer choice C: Add lithium, is incorrect. Lithium is mainly used to treat bipolar disorder but can be used as an off-label (not FDA-approved) adjunctive medication for patients with unipolar depression who have not adequately responded to antidepressant therapy. However, screening for suicidal ideation is the most important next step in management before medication is added.
Answer choice D: Increase the dose of sertraline, is incorrect. Sertraline is a selective serotonin reuptake inhibitor that can be used to treat major depressive disorder, panic disorder, obsessive-compulsive disorder, social anxiety disorder, and many other psychiatric illnesses. The dose of sertraline can be titrated up, but screening for suicidal ideation is the most important next step in management.
Key Learning Point
Any patient with acute worsening of previously controlled depressive symptoms should be assessed for suicidal ideation.
