Depressive Disorders

Match each clinical presentation of a patient with a depressive disorder to the most appropriate next step in clinical management.

A 32-year-old man presents to the outpatient clinic with a 2-month history of persistent sadness, profound fatigue, early morning awakening, and difficulty concentrating at work. He reports that his symptoms have led to a recent poor performance review. He denies suicidal ideation, psychotic symptoms, or active medical problems. Physical examination and baseline laboratory studies are unremarkable. You suspect major depressive disorder (MDD) and plan to initiate treatment. Arrange the following clinical management steps in the most appropriate chronological sequence, assuming the patient eventually requires treatment escalation due to an initial inadequate response.

A 61-year-old retired engineer is brought to the physician by his daughter for a psychiatric evaluation. Over the past five weeks, he has become increasingly withdrawn, spending most of the day in bed. He reports waking up at 3:00 AM daily and being unable to return to sleep. His daughter notes he has lost approximately 5.5 kg (12 lb) during this period and no longer shows interest in his usual hobbies, such as gardening. Two weeks ago, the patient's primary care provider diagnosed him with a major depressive episode and prescribed fluoxetine. The patient states he feels no better and wants to discontinue the medication. Upon further questioning, the daughter recalls that when her father was in his late thirties, he was briefly given a different antidepressant for sadness. Within days of starting that medication, he became excessively talkative, slept only two hours a night for a week, and impulsively bought three luxury vehicles, leading to a brief psychiatric hospitalization. Medical history is otherwise unremarkable, and he takes no other medications. Vital signs are within normal limits. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation with the most appropriate next step in pharmacological or procedural management.

Match the following patient clinical profiles with the most appropriate next step in management.

Evaluate the clinical scenarios below and match each patient to the most appropriate next step in psychiatric management.

A $31$-year-old man presents via telehealth for an initial psychiatric evaluation. He reports a $7$-week history of persistent low mood, extreme lethargy, and a $6$-kg ($13$-lb) weight gain. He sleeps up to $15$ hours a day and describes his limbs as feeling 'unnaturally heavy.' For the past $2$ weeks, he has also been hearing a distinct, critical voice telling him he is 'toxic and contagious' whenever he is alone in his room. Upon detailed psychiatric history taking, he reveals that $3$ years ago, he was hospitalized for a $10$-day period during which he believed he was a divine messenger, slept only $1$ hour per night, and paced the streets preaching. He was stabilized and discharged but stopped his prescribed medications shortly afterward. He recently began taking a high-dose over-the-counter St. John's wort supplement to improve his mood, but it has provided no relief. A recent primary care blood panel shows a thyroid-stimulating hormone (TSH) level of $2.1$ mU/L (normal: $0.5$-$5.0$) and a free thyroxine (T4) level of $1.1$ ng/dL (normal: $0.8$-$1.8$). Which of the following is the most appropriate next step in the management of this patient?

A 37-year-old man comes to the psychiatrist complaining of feeling "completely empty" for the past 2 months. He reports that he has lost interest in his architectural work, which he usually loves, and struggles to get out of bed before noon. His appetite has decreased, leading to an 8-lb (3.6-kg) weight loss. He expresses intense guilt over a minor calculation mistake he made on a project a year ago. A review of his past medical records reveals an emergency department visit 3 years ago for acute agitation. During that visit, he was speaking so quickly he was difficult to understand, claimed he had discovered the secret to limitless energy, and had not slept in 5 days. He was stabilized on a medication that he subsequently stopped taking because he felt it blunted his creativity. His vital signs and physical examination today are unremarkable. Which of the following is the most appropriate next step in the pharmacologic management of this patient's current symptoms?

Select the most appropriate initial pharmacological or procedural intervention for each of the following patients presenting with distinct clinical features of major depressive disorder.

A 28-year-old woman presents to the clinic complaining of feeling "down" and "exhausted" for the past month. She reports struggling to get out of bed, losing interest in her hobbies, and experiencing a 3-kg (6.6-lb) weight gain. She has difficulty concentrating at work. Four years ago, she had a period lasting about a week where she felt "on top of the world," required only 3 hours of sleep a night, and started a business that quickly failed, accumulating significant debt. She is currently not taking any medications. Her vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mm Hg, pulse 72/min, and respirations 14/min. Physical examination shows no abnormalities. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $2.1 \text{ mU/L}$ and a free thyroxine (T4) level of $1.2 \text{ ng/dL}$. Which of the following is the most appropriate initial pharmacotherapy for this patient?

A 42-year-old woman is evaluated in the psychiatric clinic and diagnosed with a moderate major depressive episode without psychotic features. Over the next 18 months, she requires multiple adjustments to her treatment plan due to inadequate symptom relief. Ultimately, her condition deteriorates, and she develops severe psychotic depression with delusions of guilt and total refusal to consume food or fluids. According to standard clinical guidelines for the stepped-care management of major depressive disorder, arrange the following therapeutic interventions in the most appropriate chronological sequence of escalation.

A 22-year-old college student presents to the university outpatient clinic reporting a 5-week history of feeling profoundly sad, crying frequently, and lacking the motivation to attend her classes. She reports sleeping up to 12 hours a day and eating significantly more than usual, resulting in a 4 kg (8.8 lb) weight gain. She has no significant past medical history, and her vital signs are within normal limits. Laboratory tests, including a complete blood count and thyroid-stimulating hormone (TSH) level, are normal. She currently takes no medications or illicit substances. The physician suspects a major depressive episode and plans to prescribe fluoxetine. Which of the following is the most appropriate next step in the clinical evaluation and management of this patient?

A 26-year-old woman is brought to the clinic by her sister due to a 5-week history of severe depression. The patient describes her mood as "bottomless" and complains that her arms and legs constantly feel "heavy as lead." She reports sleeping 14 to 16 hours daily and has gained 6 kg (13.2 lb) over the past month, which she attributes to intense carbohydrate cravings. Despite her profound sadness, the sister notes that the patient's mood brightened considerably yesterday when she was presented with a surprise gift, though she relapsed into despondency hours later. The patient has experienced two similar depressive episodes in the past. The sister confidentially shares that during the patient's sophomore year of college, there was a distinct 10-day period where she seemed "like a completely different person." During that time, she slept only 3 hours a night without feeling fatigued, rapidly repainted her entire apartment, and abruptly spent her tuition money on a business venture that never materialized. She has no significant past medical history. Physical examination is unremarkable. Which of the following is the most appropriate next step in pharmacotherapy for this patient?

A 29-year-old woman presents to the clinic 4 weeks postpartum for a follow-up evaluation. She reports feeling profoundly sad, tearful, and unable to enjoy time with her newborn. She states, "I feel completely overwhelmed and guilty for being a terrible mother." She wakes up at 3:00 AM every day and is unable to fall back asleep, despite her husband handling the nighttime feedings. She has a poor appetite and has lost 4.5 kg (10 lb) since her delivery. She denies any thoughts of harming herself or her infant. She had an uncomplicated vaginal delivery but required a second-degree perineal laceration repair; she takes tramadol occasionally for residual pain. When reviewing her psychiatric history, she mentions that during her sophomore year of college, she experienced a distinct 5-day period where she felt "invincible," required only 2 hours of sleep per night, and started three different student organizations while speaking so rapidly her friends could hardly understand her. This college episode resolved spontaneously without hospitalization. Which of the following is the most appropriate next step in management?

A 47-year-old male executive seeks psychiatric evaluation for profound sadness, early morning awakening, and severe anhedonia that have progressively worsened over the past four months. His past medical history is unremarkable, and he is currently taking no medications. Arrange the following therapeutic steps in the exact sequence recommended by standard clinical guidelines for the progressive pharmacological and procedural management of major depressive disorder. Assume that each step is implemented sequentially only after the preceding intervention has yielded an inadequate clinical response (either non-response or insufficient partial response) despite optimal dosing and duration.

A 29-year-old man presents to the outpatient clinic reporting a 6-week history of feeling "down and hopeless." He states that he has lost interest in his usual hobbies, has very low energy, and is sleeping up to 12 hours a day. His appetite has increased, leading to a 4-kg (8.8-lb) weight gain. He was recently reprimanded at work for excessive absences because he could not find the motivation to get out of bed. He has no significant past medical history and takes no medications. He does not use tobacco, alcohol, or illicit substances. He mentions that occasionally, just as he is falling asleep, he hears a voice calling his name. Physical examination reveals a flat affect and psychomotor retardation, but no other abnormalities. He requests to be started on an antidepressant medication. Which of the following is the most appropriate next step in the management of this patient?

A 34-year-old woman presents to the clinic with a 6-week history of profound sadness, anhedonia, and terminal insomnia. She reports significant functional impairment, having recently taken a leave of absence from her job due to a severe inability to concentrate. Review of systems is notable for a 4.5-kg (10-lb) weight loss and mild psychomotor agitation. Thorough psychiatric screening confirms the absence of any past manic or hypomanic episodes, ruling out bipolar disorder. Over the next 14 months, her major depressive disorder exhibits a complex trajectory, requiring a progressive, stepped-care escalation of her management plan according to standard psychiatric guidelines. Arrange the following clinical interventions in the most appropriate chronological sequence, beginning with her initial presentation and escalating to the management of life-threatening psychiatric complications.

A 54-year-old software developer with no prior psychiatric history is evaluated for Major Depressive Disorder (MDD). Arrange the following pharmacological and somatic management steps in the correct chronological sequence according to standard stepped-care escalation protocols, starting from the initial presentation to the eventual management of a severe, life-threatening refractory state.

A 31-year-old woman is evaluated in the clinic for severe mood changes. She delivered her first child 5 months ago without complications. Over the past 8 weeks, she has experienced profound sadness, anhedonia, and a 5-kg (11-lb) weight loss. She awakens at 3:00 AM daily and cannot return to sleep. She notes her depressed mood is worst in the mornings and is completely unreactive to positive events, including playing with her infant. Two weeks ago, her primary care physician prescribed escitalopram; however, she discontinued it 4 days ago, stating it was ineffective. Her husband reports that five years ago, she had a 7-day episode where she slept only 2 hours per night, spoke incessantly, and compulsively purchased thousands of dollars of baby clothes despite not being pregnant. She has no other medical conditions and does not use illicit substances. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in the management of this patient?

A psychiatry resident is evaluating five different patients presenting with depressive symptoms in various clinical settings. Match each patient's clinical vignette with the most appropriate best next step in management or definitive diagnosis.