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.
- 1Screen for a prior history of manic or hypomanic episodes
- 2Initiate monotherapy with a selective serotonin reuptake inhibitor
- 3Augment the regimen with a second-generation antipsychotic
- 4Refer for electroconvulsive therapy
Cevap
The correct chronological sequence is: 1) Screen for a prior history of manic or hypomanic episodes, 2) Initiate monotherapy with a selective serotonin reuptake inhibitor, 3) Augment the regimen with a second-generation antipsychotic, 4) Refer for electroconvulsive therapy.
The standard approach to a new depressive episode requires first ruling out bipolar disorder by screening for past mania or hypomania. Once unipolar depression is established, a selective serotonin reuptake inhibitor is the preferred first-line treatment. If the patient has a partial response despite an adequate trial and dose optimization, augmentation with an agent like a second-generation antipsychotic is indicated. Electroconvulsive therapy is generally reserved for severe, highly treatment-resistant depression that has not responded to multiple pharmacological interventions.
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Anahtar Kavram
The stepped-care management of major depressive disorder begins with ruling out bipolar disorder, followed by initial SSRI monotherapy, subsequent augmentation for partial responders, and eventually ECT for severe, refractory cases.