Major depressive disorder is a common mood disorder with low mood or loss of interest for at least 2 weeks, plus other symptoms that affect daily life. It is treatable, and every patient must be asked about suicide.
Key symptoms
- Low mood most of the day, nearly every day
- Loss of interest or pleasure in usual activities
- Changes in sleep and appetite, low energy
- Poor concentration, guilt or feeling worthless
- Thoughts of death or suicide
What you find on exam
- Mental status exam: appearance, slow speech and movement, flat affect
- Direct questions about suicidal thoughts, plan, intent and access to means
- Ask about past mania to rule out bipolar disorder
- Screen for alcohol and drug use
Tests
- PHQ-9 to screen and track severity
- Blood count, thyroid tests and metabolic panel to exclude medical causes
- Other tests, such as B12 or a pregnancy test, guided by the history
Treatment basics
- Psychotherapy, such as cognitive behavioral therapy
- Antidepressants: an SSRI such as sertraline or escitalopram is a common first choice
- Explain that benefit takes 4 to 6 weeks; continue at least 6 to 12 months after recovery
- Close follow-up, especially in young adults starting medication
- Severe or psychotic depression: urgent psychiatry; ECT is an option
Red flags
- Suicidal thoughts with a plan or access to means
- Psychotic symptoms, or not eating or drinking
- Signs of mania after starting an antidepressant
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Related guides
Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.