Depressive Disorders

A 28-year-old woman presents to her primary care physician reporting a 6-week history of pervasive sadness, loss of interest in her usual hobbies, significant fatigue, and difficulty concentrating at work. She has no past medical history and takes no medications. Physical examination and initial laboratory studies, including a thyroid-stimulating hormone level, are unremarkable. The physician determines she meets the criteria for a major depressive episode and considers initiating a selective serotonin reuptake inhibitor. Which of the following is the most critical historical information to obtain before prescribing this medication?

For each patient vignette describing a mood-related presentation, select the most appropriate primary treatment modality or specific medication.

A 34-year-old man comes to the primary care clinic complaining of dizziness, nausea, vivid nightmares, and "electric shock-like" sensations in his head for the past 3 days. He has a history of major depressive disorder, which has been well-controlled on paroxetine for the past year. During the interview, he mentions that he felt completely back to normal, so he abruptly stopped taking his medication 4 days ago. His vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in management?

A 64-year-old man is evaluated in the outpatient clinic for a severe major depressive episode 3 months after suffering an acute anterior myocardial infarction. He is currently hemodynamically stable and compliant with his post-myocardial infarction medical regimen, which includes dual antiplatelet therapy. He reports pervasive anhedonia, early morning awakening, profound fatigue, and feelings of worthlessness. Over the subsequent 18 months, despite extensive medical management, his depressive disorder proves highly resistant to standard therapies, eventually precipitating a severe clinical deterioration characterized by extreme food refusal, profound dehydration, and catatonic posturing requiring emergent hospitalization.

Arrange the following psychiatric management steps in the most appropriate, evidence-based chronological sequence for this patient, from initial evaluation in the outpatient clinic to the management of his final acute decompensation.

Match each patient's presentation of a depressive disorder or related mood disturbance with the most appropriate therapeutic intervention.

A 37-year-old man is brought to the clinic by his sister due to a 6-week history of profound fatigue, hypersomnia, and a 4-kg (9-lb) weight gain. He states he feels completely devoid of energy, struggles to get out of bed, and expresses unwarranted guilt over taking time off from his job as an accountant. His sister notes that three years ago, the patient experienced a highly unusual two-week period during which he slept only three hours a night, exhibited pressured speech, and impulsively emptied his savings account to invest in unproven cryptocurrency. He has no other medical history and takes no medications. Vital signs are within normal limits. Laboratory evaluation shows a thyroid-stimulating hormone (TSH) level of 2.1 µU/mL (normal: 0.5-5.0 µU/mL) and a normal free T4 level. Which of the following is the most appropriate initial pharmacotherapy for this patient?

A $68$-year-old man is brought to the geriatric clinic by his daughter for a follow-up evaluation. For the past $3$ months, he has experienced profound sadness, anhedonia, early morning awakenings, and a $6$-kg ($13$-lb) weight loss. Three weeks ago, he began stating that his "stomach has turned to dust" and now frequently refuses to eat.

Three weeks ago, his primary care physician diagnosed a major depressive episode and prescribed citalopram. The patient took it for $14$ days but stopped it entirely $7$ days ago because "it wasn't doing anything." His past medical history includes severe osteoarthritis, for which he takes daily tramadol.

His daughter privately reports that when the patient was $32$ years old, he had a distinct $6$-week period where he slept only $2$ hours a night, exhibited pressured speech, and impulsively bought two boats, which led to a brief psychiatric hospitalization.

Vital signs are within normal limits. Physical examination is unremarkable.
Laboratory results show:
- Thyroid-stimulating hormone (TSH): $1.2$ $\mu$ U/mL (normal: $0.4$–$4.0$ $\mu$ U/mL)
- Free thyroxine (T4): $0.5$ ng/dL (normal: $0.9$–$2.4$ ng/dL)

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

A 26-year-old man comes to the clinic for a follow-up visit. Three weeks ago, he was diagnosed with major depressive disorder after presenting with a 6-week history of depressed mood, anhedonia, significant weight loss, and severe fatigue. At his initial evaluation, a comprehensive psychiatric history confirmed the absence of any past episodes of abnormally elevated mood, impulsivity, or decreased need for sleep. He was started on sertraline 50 mg daily. Today, the patient reports that his sleep has improved slightly, but he still feels sad most days and lacks the energy to resume his usual hobbies. He denies suicidal ideation, auditory hallucinations, or racing thoughts. His vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in management?

During a follow-up visit at the university health center, a 24-year-old graduate student reports persistent feelings of profound sadness and lack of motivation that have severely impacted her studies over the past eight weeks. She mentions sleeping 11 to 13 hours daily, a recent 5-kg (11-lb) weight gain, and a sensation that her limbs are "made of lead." Two weeks prior to this visit, a physician prescribed citalopram. The patient reveals she abruptly stopped taking it three days ago due to mild nausea and a belief that "the pills were completely useless." While exploring her psychiatric history, she mentions a distinct 2-day period during her freshman year when she felt "euphoric and full of energy," requiring only a few hours of sleep while celebrating the end of final exams with friends. Her mood returned to baseline shortly after the weekend. She currently takes no medications and uses no illicit substances. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old woman is brought to the emergency department by her son due to progressive behavioral changes over the past 5 weeks. She has developed profound sadness, anhedonia, and terminal insomnia, typically waking at 3:00 AM and unable to return to sleep. For the past week, she has refused all food and water, repeatedly stating, "My stomach has turned to dust, it cannot process anything." She has lost 6 kg (13.2 lbs) during this period. Her medical history is significant for Parkinson disease, for which she has been taking carbidopa-levodopa and selegiline for three years.

Vital signs show a blood pressure of 96/60 mmHg and a heart rate of 112/min. Physical examination reveals severely dry mucous membranes and decreased skin turgor.

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

A 28-year-old woman, 3 months postpartum, is brought to the clinic by her husband for a psychiatric evaluation. She has been exclusively formula-feeding her infant. For the past 4 weeks, she has experienced profound sadness, frequent crying spells, excessive sleepiness, and an inability to care for her baby. She states, "I am a terrible mother and my baby deserves better." Three weeks ago, her obstetrician prescribed sertraline, but she discontinued it after 5 days because she "felt it wasn't working fast enough." Her husband notes that 4 years ago, she had a 2-week period where she slept only 2 hours a night, spoke rapidly, and claimed she was chosen by God to lead a new religion; this episode required a brief psychiatric hospitalization. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $110/70 \text{ mm Hg}$, and pulse is $78/\text{min}$. Physical examination is unremarkable. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $1.5 \ \mu\text{U/mL}$ (normal: $0.5-5.0$). She is currently taking no medications. 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 management or pharmacotherapy.

Match each patient's clinical presentation with the most appropriate tailored pharmacotherapy or neuromodulation therapy.

Match each patient's clinical vignette to the most accurate psychiatric diagnosis.

A 45-year-old man presents to the clinic with a 6-week history of persistently depressed mood, profound anhedonia, terminal insomnia, 5-kg (11-lb) weight loss, and difficulty concentrating. He denies any suicidal ideation and exhibits no psychotic features. He has no prior psychiatric or medical history and is currently treatment-naive. Based on standard clinical guidelines, arrange the following management steps in the most appropriate chronological sequence for this patient. Assume that at each subsequent step, the patient experiences an inadequate clinical response despite adequate trial duration, documented medication adherence, and good tolerability.

Match each patient's clinical presentation with the most appropriate next step in management or specific therapeutic intervention.

A 38-year-old female presents to the clinic with an 8-week history of depressed mood, significant weight loss, early morning awakenings, and severe anhedonia, causing her to take a leave of absence from work. Over the subsequent 14 months, her clinical condition progresses through multiple phases of treatment resistance, eventually culminating in a psychiatric admission for active suicidal ideation with a specific plan. Arrange the following clinical actions in the correct chronological sequence according to evidence-based management guidelines for this patient's evolving condition, from her initial presentation through her eventual inpatient admission.

A 32-year-old woman is brought to the emergency department by her sister due to a 3-week history of worsening social withdrawal, profound sadness, and extreme fatigue. The patient sleeps up to 15 hours a day and frequently states, "Everyone would be better off without me." Her sister notes the patient recently stopped attending her job as an accountant.

Review of her medical history reveals a depressive episode three years ago, for which her primary care physician prescribed fluoxetine. Three weeks into that treatment, the patient abruptly quit a previous job, flew to another continent alone, and spent her entire life savings over the course of seven days while sleeping less than two hours per night. She was hospitalized abroad, the fluoxetine was discontinued, and her mood gradually stabilized over the next month.

The patient currently takes no medications and uses no illicit substances. Vital signs are within normal limits. Physical examination reveals a flat affect and psychomotor retardation.

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

During a routine telehealth appointment, a 28-year-old marketing executive describes a 6-week history of worsening dysphoria, profound anhedonia, and debilitating fatigue. She reports sleeping up to 12 hours a day and experiencing a 5-kg (11-lb) weight gain over this period. The patient expresses excessive guilt over her recent decline in work performance. She has no significant past medical history and does not consume alcohol or illicit substances. The physician considers initiating pharmacotherapy with a selective serotonin reuptake inhibitor. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's comprehensive clinical vignette to the most accurate psychiatric diagnosis.