A 44-year-old woman sees her primary care physician for worsening depressive symptoms. She was diagnosed with major depression by her psychiatrist, which was previously well controlled with sertraline (Zoloft), 50 mg daily. On exam, VS are WNL, however, the patient has a flat affect and becomes tearful during the clinical interview. You administer the Patient Health Questionnaire-9 (PHQ-9) to re-evaluate her depression and she scores a 16, with a previously documented score of 8 in her chart.
Which of the following is the most important next step in management?
- A) Add aripiprazole (Abilify)
- B) Add brexpiprazole (Rexulti)
- C) Increase sertraline
- D) Add lithium
- E) Inquire about suicidal ideation
E) Inquire about 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. 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). 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. Depression often initially presents in the primary care setting but are underdiagnosed because screening is frequently underperformed.
Key Learning Point
Any patient with acute worsening of previously controlled depression should be assessed for suicidal ideation.
Dr. Raj Dasgupta
Dr. Raj Dasgupta