Major Depressive Disorder - CCS Case Guide
Key Takeaway: Major depressive disorder is one of the most common psychiatric conditions encountered on CCS. The key to scoring well is performing a thorough safety assessment, screening with validated tools like the PHQ-9, ruling out medical and substance-related causes of depressive symptoms, initiating first-line pharmacotherapy, arranging psychotherapy, and establishing close follow-up to monitor treatment response and suicidality.
Major depressive disorder is one of the most common psychiatric conditions encountered on CCS. The key to scoring well is performing a thorough safety assessment, screening with validated tools like the PHQ-9, ruling out medical and substance-related causes of depressive symptoms, initiating first-line pharmacotherapy, arranging psychotherapy, and establishing close follow-up to monitor treatment response and suicidality.
Recognizing the Major Depression Presentation
- History: Depressed mood or anhedonia for ≥2 weeks, with associated sleep changes (insomnia or hypersomnia), appetite changes, fatigue, poor concentration, psychomotor retardation or agitation, guilt, and suicidal ideation
- PHQ-9 Screening: Score ≥10 suggests moderate depression; ≥15 suggests moderately severe; ≥20 suggests severe depression
- Mental Status Exam: Flat or constricted affect, psychomotor retardation, poor eye contact, slow speech, tearfulness, possible hopelessness
- Safety Assessment: Directly ask about suicidal ideation, plan, intent, access to means, prior attempts, and protective factors
- Social History: Recent losses, relationship problems, financial stress, substance use, social isolation, family history of depression or suicide
- Medical History: Hypothyroidism, anemia, chronic pain, malignancy, neurologic disease, and medications (beta-blockers, corticosteroids, interferon) that may cause depressive symptoms
Immediate Actions (First 5 Minutes)
These orders should be placed immediately — timing is scored:
Critical First Orders
- ✓ Perform structured suicide risk assessment (ideation, plan, intent, means, prior attempts)
- ✓ If actively suicidal: psychiatry consult, 1:1 observation, remove access to means
- ✓ Administer PHQ-9 for severity quantification
- ✓ Order TSH and CBC to rule out medical causes
- ✓ Screen for substance use and bipolar disorder (rule out mania before starting SSRI)
- ✓ Establish therapeutic alliance and discuss treatment options
Complete Workup
After initial stabilization, complete the diagnostic workup:
- PHQ-9 score
- Columbia Suicide Severity Rating Scale (C-SSRS) if suicidal ideation present
- TSH (hypothyroidism)
- CBC (anemia)
- BMP (electrolytes, renal function)
- Vitamin B12 and folate levels
- Urine drug screen
- Hepatic function panel (baseline before medication)
- Screen for bipolar disorder with Mood Disorder Questionnaire (MDQ)
- Consider brain MRI if focal neurologic signs or late-onset first episode
Treatment
Pharmacotherapy
- First-line: SSRI (sertraline 50 mg daily or escitalopram 10 mg daily)
- Counsel that therapeutic effect takes 4-6 weeks
- Monitor for worsening suicidality in first 2-4 weeks (especially age <25)
- If inadequate response at 6-8 weeks, increase dose or switch SSRI
- Consider SNRI (venlafaxine, duloxetine) or bupropion as alternatives
Psychotherapy
- Refer for cognitive behavioral therapy (CBT) — first-line psychotherapy
- Combination of medication + therapy is more effective than either alone
- Interpersonal therapy (IPT) is an evidence-based alternative
Safety Planning
- Develop written safety plan with warning signs, coping strategies, and emergency contacts
- Restrict access to lethal means (firearms, medications)
- Provide crisis hotline number (988 Suicide and Crisis Lifeline)
Severe or Refractory Depression
- Inpatient psychiatric admission for imminent suicide risk
- Electroconvulsive therapy (ECT) for severe, refractory, or psychotic depression
- Augmentation strategies: lithium, atypical antipsychotics (aripiprazole, quetiapine)
Common Pitfalls
Scoring Tip: These are the most commonly missed actions for Major Depression cases.
- Failing to ask directly about suicidal ideation and plan
- Not screening for bipolar disorder before starting an SSRI (can precipitate mania)
- Prescribing benzodiazepines for depression without addressing underlying MDD
- Not ruling out hypothyroidism and other medical causes
- Stopping SSRI too early or not allowing adequate trial duration (4-6 weeks)
- Forgetting to schedule close follow-up (1-2 weeks after SSRI initiation)
Disposition
- Outpatient management for mild-to-moderate depression without active suicidality
- Inpatient psychiatric admission for active suicidal ideation with plan or intent
- Follow-up in 1-2 weeks after SSRI initiation to assess response and side effects
- Psychiatry referral for treatment-resistant cases or comorbid psychiatric conditions
Key Orders Checklist
- ☐ PHQ-9 administration
- ☐ Suicide risk assessment
- ☐ TSH level
- ☐ CBC
- ☐ BMP
- ☐ Urine drug screen
- ☐ Sertraline 50 mg daily (or escitalopram 10 mg daily)
- ☐ CBT referral
- ☐ Psychiatry consult (if severe)
- ☐ Safety plan documentation
- ☐ Follow-up appointment in 1-2 weeks
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