A 36-year-old woman presents to her primary care physician due to fatigue, poor sleep, and feelings of worthlessness for the past 2 months. She reports a loss of interest in activities she previously enjoyed and has experienced unintentional weight loss. She denies suicidal ideation, hallucinations, or delusions. She denies any history of manic episodes. She has no significant past medical history and takes no medications. She does not drink alcohol, smoke cigarettes, or use illicit substances. Family history is notable for depression in her mother. Physical examination is unremarkable. A PHQ-9 is administeed and reveals a score of 14. A complete blood count (CBC) and thyroid stimulating hormone (TSH) level are within normal limits.
D) Start a selective serotonin reuptake inhibitor
This patient meets DSM-5 criteria for Major Depressive Disorder (MDD), which requires at least 5 of the following symptoms for a minimum of 2 weeks, representing a change from previous functioning, with at least one being either depressed mood or loss of interest/pleasure (anhedonia):
- Depressed mood
- Anhedonia
- Weight/appetite changes
- Sleep disturbances
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or excessive guilt
- Diminished ability to concentrate
- Recurrent thoughts of death or suicide
This patient reports anhedonia, weight loss, insomnia, fatigue, and feelings of worthlessness, satisfying ≥5 symptoms of MDD. Her PHQ-9 score of 14 indicates a moderate major depression. There is no indication of psychosis or suicidality requiring inpatient care. SSRIs (e.g., fluoxetine, sertraline) are first-line pharmacologic treatment, especially in moderate to severe MDD. She will also benefit from psychotherapy such as cognitive-behavioral therapy, interpersonal psychotherapy, or behavioral activation therapy as psychotherapy has demonstrated efficacy for improving remission rates compared with placebo. Supplemental treatments such as exercise or bright light therapy may also be beneficial.
Answer choice A: Administer a Patient Health Questionnaire-2 (PHQ-2), is incorrect. Screening tools (e.g., PHQ-2) are useful for identifying undiagnosed depression. However, once MDD has been clearly diagnosed based on history and severity determined with a PHQ-9, treatment should proceed without delay.
Answer choice B: Prescribe aripiprazole, is incorrect. Aripiprazole is a second-generation (atypical) antipsychotic medication. Antipsychotics are not first-line for MDD unless psychotic features (e.g., delusions, hallucinations) are present. This patient does not exhibit any psychotic symptoms.is incorrect.
Answer choice C: Prescribe chlorpromazine, is incorrect. Chlorpromazine is a first-generation (typical) antipsychotic medication. Antipsychotics are not first-line for MDD unless psychotic features (e.g., delusions, hallucinations) are present. In this case, a second-generation antipsychotic agent is preferred because of side effect of first-generation agents, including movement disorders, sedation, and weight gain. This patient does not exhibit any psychotic symptoms.is incorrect.
Answer choice E: Recommend hospitalization, is incorrect. Hospitalization is appropriate when a patient is a danger to self or others, is gravely disabled, or has severe psychotic symptoms. This patient is functioning well enough to attend an outpatient visit and denies suicidal ideation.
Key Learning Point
Major depressive disorder is diagnosed when ≥5 depressive symptoms persist for ≥2 weeks and impair functioning. First-line treatment of moderate to severe MDD includes may include monotherapy with cognitive behavioral therapy versus a second-generation antidepressant (selective serotonin reuptake inhibitor or serotonin norepinephrine reuptake inhibitor) or combination therapy. The informed decision should be personalized and based on discussion of potential treatment benefits, harms, adverse effect profiles, comorbidities, concomitant medication use, and patient preferences.
