Depressive Disorders

A 28-year-old woman is diagnosed with major depressive disorder and prescribed an oral selective serotonin reuptake inhibitor (SSRI). Arrange the following clinical events and milestones in the typical chronological order in which they are expected to occur during her treatment course, from the initial days of therapy to long-term management.

A 24-year-old woman is evaluated in the psychiatric clinic for worsening mood. For the past two months, she has experienced pervasive sadness, anhedonia, hypersomnia (sleeping 12 to 14 hours a day), and a 6-kg (13-lb) weight gain. She describes her arms and legs as feeling "heavy like lead," though she notes her mood brightens temporarily when her sister comes to visit. Three years ago, she was hospitalized for a one-week episode during which she slept only two hours a night, spoke extremely rapidly, and spent her entire savings. During that admission, she heard a voice telling her she was a prophet, but this hallucination resolved completely within 5 days alongside her other symptoms after she received acute treatment. She is currently taking fluoxetine, which was prescribed by her primary care physician three weeks ago, but she reports no improvement.

Which of the following is the most appropriate next step in management?

A 72-year-old woman is brought to the emergency department by her husband due to a progressive physical decline over the past week. She has a history of persistent depressive disorder since her late 40s and was diagnosed with a superimposed major depressive episode 6 months ago following her husband's stroke. During the current episode, she sequentially failed 8-week trials of sertraline and venlafaxine at maximum tolerated doses. Four weeks ago, her psychiatrist initiated a combination of fluoxetine 40 mg and bupropion 150 mg daily. Over the past 7 days, she has entirely refused to eat or drink, stating that her "stomach has been replaced by a block of ice" and that eating is a sin. On examination, she is mute, exhibits severe psychomotor retardation, and avoids eye contact. Her temperature is 37.0°C (98.6°F), pulse is 110/min, and blood pressure is 105/65 mm Hg. Her mucous membranes are extremely dry, and skin turgor is poor. Laboratory results show a blood urea nitrogen (BUN) of 48 mg/dL and a serum creatinine of 1.9 mg/dL (baseline 4 weeks ago was 0.8 mg/dL). Which of the following is the most appropriate next step in management?

A 24-year-old graduate student presents to the clinic reporting that she has felt "down and empty" for the past 6 weeks. She describes poor appetite, waking up multiple times during the night, low energy, and an inability to enjoy her usual hobbies. She feels guilty about her recently declining academic performance. She has no significant past medical history and takes no medications. Her physical examination is unremarkable. The physician determines that she meets the criteria for a major depressive episode and considers initiating pharmacotherapy with an antidepressant. Which of the following is the most appropriate next step in the psychiatric evaluation prior to prescribing this medication?

A 42-year-old male marketing executive presents to the clinic for a two-month history of pervasive anhedonia, early morning awakening, and an unintentional 5-kg (11-lb) weight loss. He reports that his symptoms have severely impaired his concentration, leading to a recent formal reprimand at work. He is seeking pharmacologic treatment. Assuming this patient will eventually develop treatment-resistant depression over the next year, arrange the following clinical management steps in the standard chronological sequence according to evidence-based stepped-care guidelines.

A 27-year-old primigravida at 16 weeks gestation is brought to the clinic by her partner due to worsening mood. Over the last four weeks, she has felt profoundly sad, lacks energy, and sleeps up to 14 hours a day. She expresses deep guilt and says she feels "empty." Her partner notes that during her second year of college, she experienced a distinct two-week period where she slept only three hours a night, spoke at an unusually rapid pace, and started three different business ventures that rapidly failed. That prior episode resolved without hospitalization. She currently takes a daily prenatal vitamin and an over-the-counter dextromethorphan syrup for a chronic post-viral cough. Vital signs are within normal limits. Recent laboratory testing shows a thyroid-stimulating hormone (TSH) level of 1.1 mU/L. Which of the following is the most appropriate next step in pharmacologic management?

Match each depressive disorder or specifier with its most characteristic clinical presentation.

A 28-year-old woman presents to the outpatient clinic 3 months postpartum reporting an overwhelmingly sad mood, profound hypersomnia, hyperphagia, and a sensation of extreme heaviness in her arms and legs. She reports significant functional impairment, noting difficulty getting out of bed to care for her infant. To avoid common clinical pitfalls and ensure standard-of-care management, arrange the following steps in the correct chronological sequence, from the immediate diagnostic evaluation to the management of potential treatment refractoriness.

Match each patient's clinical presentation of major depressive disorder with the most appropriate initial pharmacological treatment based on their specific comorbidities and symptom profiles.

A 31-year-old woman comes to the clinic with her husband due to a 4-week history of profound sadness, frequent crying spells, and a feeling of being "completely overwhelmed." She delivered her first child 2 months ago via an uncomplicated vaginal delivery. She states that she sleeps heavily when the infant sleeps but still feels exhausted throughout the day. She has a poor appetite and expresses immense guilt over being a "terrible mother." She denies any thoughts of harming herself or the infant. Her medical history is unremarkable. Vital signs are normal. Laboratory testing shows a thyroid-stimulating hormone (TSH) level of $4.2 \mu U/mL$ (normal: $0.5-5.0 \mu U/mL$) and a free T4 of $1.1 ng/dL$ (normal: $0.8-2.8 ng/dL$). During the interview, her husband mentions that during her second trimester of pregnancy, she experienced a 3-week period where she "barely slept for days," rapidly renovated their entire house single-handedly, and spoke so quickly that he struggled to follow her train of thought. He had assumed this was a severe case of "pregnancy nesting." Which of the following is the most appropriate next step in pharmacological management?

For each of the following patient scenarios involving depressive symptoms or related disorders, select the most appropriate targeted pharmacotherapy or management step.

A 30-year-old man presents to the clinic reporting a 4-week history of persistent sadness, sleeping 12 hours a day, and lacking energy to do his usual activities. He mentions having a history of a distinct 10-day period during his college years when he felt "on top of the world," had racing thoughts, and stayed awake for days working on multiple projects without feeling tired. His only current medication is lisinopril for mild hypertension. A thyroid panel performed last week showed a TSH of 2.1 µU/mL (normal: 0.5-5.0 µU/mL) and a normal free T4. The physician is evaluating pharmacological treatment options. Which of the following statements regarding the management of this patient is most accurate?

A 34-year-old architect is brought to the emergency department by his spouse due to increasingly erratic behavior. For the past week, he has slept only two hours per night, stating he feels "more energized than ever." He has maxed out multiple credit cards purchasing expensive aviation parts to build a "revolutionary flying vehicle" in his garage. On examination, he paces around the room continuously, and his speech is so rapid and pressured that it is difficult to interrupt. His spouse reports that three weeks ago, the patient visited his primary care provider for profound sadness, hypersomnia, and anhedonia that had persisted for a month. At that visit, he was diagnosed with a psychiatric condition and started on a new daily medication. Which of the following actions by the primary care provider prior to initiating this medication would most likely have prevented the patient's current presentation?

A 42-year-old accountant is evaluated for a two-month history of pervasive sad mood, anhedonia, and poor concentration. He is seeking treatment for the first time. Arrange the following clinical steps in the standard chronological order they should be considered, starting with the initial evaluation and progressing through the escalation of care for increasingly treatment-resistant depression.

A 42-year-old executive is diagnosed with severe Major Depressive Disorder (MDD) without psychotic features. Despite excellent medication adherence, the patient's symptoms prove progressively difficult to treat over several months. Arrange the following steps in the standard evidence-based sequence for the management and escalation of care for MDD, from initial presentation through to the management of severe treatment-resistant depression.

A 72-year-old woman is brought to the emergency department by her son due to worsening confusion and refusal to eat or drink. For the past two months, she has experienced profound sadness, early morning awakenings, and a 9-kg (20-lb) weight loss. One week ago, her primary care physician diagnosed her with depression and started her on sertraline 50 mg daily. The son is unsure if the physician took a detailed psychiatric history. Over the last 3 days, the patient has stopped eating and drinking entirely, stating repeatedly, "My intestines are rotting away because of my sins." Her temperature is 37.1°C (98.8°F), blood pressure is 90/60 mm Hg, heart rate is 112/min, and respiratory rate is 16/min. Physical examination shows remarkably dry mucous membranes and decreased skin turgor.

After initiating intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation to the most appropriate depressive disorder subtype or related diagnosis.

A 42-year-old woman presents to the oncology clinic for a routine follow-up. She was diagnosed with estrogen receptor-positive breast cancer 8 months ago, underwent a lumpectomy and radiation therapy, and is currently taking tamoxifen. When asked about her general well-being, she reports an 8-week history of profound fatigue, sleeping up to 14 hours a day, increased appetite with a 4-kg (8.8-lb) weight gain, and a heavy, "leaden" feeling in her arms and legs that makes it difficult to get out of bed. Her functional impairment is significant, and she recently took a leave of absence from her job. A review of her psychiatric history reveals a similar depressive episode at age 22. Further questioning reveals that at age 24, she experienced a 5-day period where she felt "euphoric and invincible," required only 3 hours of sleep per night, and rapidly outlined a 300-page screenplay. This period resolved spontaneously without hospitalization. Last week, her primary care physician diagnosed her with depression and prescribed paroxetine, but the patient discontinued it after 2 days due to mild nausea. She currently takes no medications other than tamoxifen. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in the pharmacological management of this patient's psychiatric symptoms?

A 65-year-old man comes to the clinic accompanied by his husband. He has a history of early-stage colon cancer that was surgically resected $6 \text{ months}$ ago. For the past two months, the patient has experienced pervasive sadness, a $6 \text{ kg}$ ($13.2 \text{ lb}$) weight loss, severe insomnia, and a complete lack of energy. He has also developed the conviction that his cancer is a direct punishment for his past mistakes. He states, "I just need an antidepressant to get my life back." His only current medication is lisinopril for hypertension. Laboratory studies reveal a low free thyroxine (T4) level and a normal thyroid-stimulating hormone (TSH) level of $1.2 \text{ mIU/L}$. Which of the following is the most appropriate next step in the evaluation and management of this patient?

A 61-year-old man, currently in remission from colon cancer, is evaluated in the oncology survivorship clinic for a 2-month history of pervasive low mood, anhedonia, severe fatigue, and feelings of worthlessness. He is not currently taking any psychiatric medications and has no prior psychiatric history. Based on standard psychiatric guidelines for the stepped-care management of Major Depressive Disorder (MDD), arrange the following clinical steps in the most appropriate chronological sequence, assuming the patient exhibits inadequate responses to initial treatments and eventually develops life-threatening clinical features.