Depressive Disorders

A $28$-year-old software engineer presents to the clinic with a $4$-week history of profound sadness, poor concentration, and a $5$-kg ($11$-lb) weight gain. She reports sleeping up to $14$ hours a day and feeling a "heavy sensation" in her arms and legs. She has stopped attending social events and is struggling to meet her project deadlines. Her medical history is unremarkable, and she takes no medications. When asked about past psychiatric symptoms, she recalls a $6$-day period during college when she felt "unstoppable," slept only $2$ to $3$ hours a night without feeling tired, and wrote an entire novel. During that time, friends noted she was speaking much faster than usual, though her behavior did not result in hospitalization or academic failure. Vital signs are within normal limits. Laboratory results show a thyroid-stimulating hormone level of $1.8 \mu U/mL$ (normal: $0.5$ to $5.0 \mu U/mL$) and a negative urine toxicology screen. Which of the following is the most appropriate next step in pharmacotherapy for this patient?

A 34-year-old graphic designer comes to the office for a follow-up visit. Four weeks ago, she presented with pervasive sadness, hypersomnia, increased appetite, and a heavy feeling in her limbs. She was diagnosed with a major depressive episode and started on sertraline 50 mg daily. Today, she reports that her mood has not improved and she is frustrated. She says, "I stopped taking the pill three days ago because it wasn't working fast enough. Can we just try something else?" Upon further questioning, the patient mentions that three years ago, she experienced a 10-day period where she felt "incredibly energized," required only 2 hours of sleep per night without feeling tired, and impulsively drained her savings account to start a speculative business venture that quickly failed. She has no history of hallucinations or delusions. Physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A 45-year-old man is diagnosed with a first episode of severe, non-psychotic major depressive disorder. He is medically healthy and has no previous psychiatric treatment history. According to standard stepped-care guidelines for major depressive disorder, arrange the following therapeutic management steps in the most appropriate chronological sequence, assuming the patient exhibits only a partial response to each consecutive intervention.

A 29-year-old woman presents to the primary care clinic reporting a 6-week history of depressed mood, profound fatigue, and an inability to concentrate at work. She notes that her appetite has significantly increased, leading to a 4-kg (8.8-lb) weight gain. She often sleeps for 12 hours a night but still wakes up feeling unrefreshed, and states that her arms and legs frequently feel "like lead." Her medical history is unremarkable, and she takes no medications. Her vital signs are within normal limits. She recalls experiencing a similar episode of depression during her first year of college, which eventually resolved without treatment. The physician is considering initiating pharmacotherapy for her symptoms. Which of the following is the most appropriate next step in management?

A 45-year-old man with no prior psychiatric history is diagnosed with Major Depressive Disorder. Over the next two years, his condition proves difficult to manage, requiring escalating interventions based on his varying levels of therapeutic response at each stage. According to evidence-based guidelines for stepped-care psychiatric management, arrange the following clinical interventions in the most appropriate chronological order, progressing from initial presentation to the management of severe treatment-resistant depression.

A 26-year-old male graduate student presents to the university health center complaining of severe sadness, lack of motivation, and poor concentration over the past 5 weeks. He states he has completely lost interest in his coursework and hobbies, which is highly unusual for him. He struggles to get out of bed, sleeping up to 14 hours a day, and reports a 5 kg (11 lb) weight gain during this time. Medical history is unremarkable, and he takes no medications. Physical examination reveals psychomotor retardation and a blunted affect, but vital signs and the remainder of the examination are within normal limits. He denies any suicidal ideation. The patient requests an antidepressant medication to help him "get back on track." Which of the following is the most appropriate next step in the clinical evaluation or management of this patient?

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

A 35-year-old man is diagnosed with major depressive disorder in the outpatient clinic. Over the next year, he experiences persistent symptoms despite good medication adherence, requiring a progressive escalation of his treatment plan. Arrange the following management steps in the standard chronological order for escalating treatment of major depressive disorder, proceeding from initial pharmacological therapy to the management of highly refractory disease.

A 24-year-old woman is brought to the clinic by her husband due to severe sadness and social withdrawal for the past 6 weeks. She has been sleeping 12 to 14 hours a day, has poor appetite, and struggles to concentrate on daily tasks. She frequently complains of feeling cold. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 1.5 µU/mL and a normal free T4 level. Her husband notes that two years ago, she had a 3-week period where she barely slept, spoke so rapidly it was hard to interrupt her, and recklessly spent thousands of dollars on unneeded home renovations. The patient is currently not taking any medications. Which of the following is the most appropriate next step in management?

A 24-year-old woman is brought to the emergency department by her husband due to worsening depressive symptoms over the past 3 weeks. She reports feeling profoundly sad, sleeping up to 14 hours a day, and experiencing significant psychomotor retardation. For the past 2 weeks, she has been hearing a persistent voice telling her that she is "worthless and should die," and she admits to having a specific plan to overdose on her medications. Her husband reports that 3 years ago, she had a distinct 1-week period where she barely slept, exhibited grandiose behavior, and engaged in impulsive spending that resulted in severe financial debt. Three days ago, her primary care provider diagnosed her with major depressive disorder and started her on fluoxetine. Laboratory studies reveal a thyroid-stimulating hormone (TSH) level of $0.2 \text{ mU/L}$ (normal: $0.5-5.0 \text{ mU/L}$) and a free T4 of $0.6 \text{ ng/dL}$ (normal: $0.9-1.7 \text{ ng/dL}$). Which of the following is the most appropriate next step in management?

A 32-year-old woman comes to the outpatient clinic 4 months postpartum for a follow-up evaluation of depressive symptoms. Two weeks ago, she presented with a 4-week history of profound despondency, early morning awakenings, anorexia with a 3-kg (6.6-lb) weight loss, and feeling worse in the morning. She reported that these symptoms made it exceedingly difficult to get out of bed and properly care for her infant. At that time, she was diagnosed with major depressive disorder and started on escitalopram 10 mg daily. Today, she states, "The medication isn't working. I still feel incredibly depressed, but now I also feel extremely restless, jittery, and my thoughts are racing." Vital signs are within normal limits. On examination, the patient appears visibly agitated, is pacing the room, and exhibits rapid speech. Upon detailed psychiatric review, she mentions that during her second year of college, she experienced a spontaneous 6-day period where she felt "incredibly energized," slept only 3 hours per night without fatigue, and impulsively maxed out two credit cards on unnecessary clothing. That episode resolved without medical intervention. Which of the following is the most appropriate next step in pharmacotherapy?

A 54-year-old male architect is evaluated for a first episode of pervasive sadness, early morning awakening, and severe anhedonia. Over the subsequent 14 months, his clinical course is characterized by progressive treatment resistance, ultimately culminating in an inpatient psychiatric admission for life-threatening symptoms. According to evidence-based stepped-care guidelines for Major Depressive Disorder, arrange the following management steps in the most appropriate chronological order, corresponding to his clinical evolution from initial presentation to severe, refractory illness.

A 31-year-old male accountant presents to the clinic for an urgent follow-up appointment. He initially presented two weeks ago with a one-month history of severe sadness, hypersomnia, and profound anhedonia. At that time, he was diagnosed with a major depressive episode and prescribed fluoxetine. Today, he reports that his mood has not improved, but he now feels "extremely irritable, wired, and completely unable to sit still." His physical examination is notable for rapid, pressured speech and psychomotor agitation. Upon detailed psychiatric review, the patient admits that he experienced a similar "wired" state twice in his twenties. During those episodes, which each lasted approximately ten days, he required only two hours of sleep per night and impulsively spent thousands of dollars on unneeded electronics. He has no significant past medical history and denies any illicit substance use. Which of the following is the most appropriate next step in management?

A 62-year-old man comes to the cardiology clinic for a routine follow-up 6 weeks after being hospitalized for an acute anterior wall myocardial infarction, for which he received a drug-eluting stent. His cardiac function has stabilized, and he is compliant with his medication regimen, which includes aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin. Today, his wife expresses deep concern about his emotional well-being since discharge. The patient states, 'My life is basically over. I am just a burden to my family now, and there is no point in going on.' He reports a 10-lb (4.5-kg) weight loss due to poor appetite and says he wakes up every day at 3:00 AM unable to fall back asleep. He admits to recurrent thoughts that his family would be better off if he were dead, though he lacks a specific suicide plan. His physical examination is unremarkable, and an electrocardiogram shows normal sinus rhythm with a QTc interval of 420 ms. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 34-year-old woman comes to the clinic reporting a 6-week history of pervasive sadness, frequent tearfulness, and profound fatigue. She states that her arms and legs feel "like they are made of lead" and she is sleeping up to 14 hours a day. She feels immense guilt about being an inadequate mother to her 4-month-old infant, whom she is exclusively breastfeeding. Three years ago, the patient was prescribed paroxetine for generalized anxiety. Two weeks after starting the medication, she became unusually energetic, slept only 2 hours a night without feeling tired, and began making impulsive, large investments in cryptocurrency, which depleted her savings. The paroxetine was immediately discontinued, but her hyperactive and grandiose state persisted for another 5 weeks before gradually resolving. She has not taken any psychiatric medications since that time. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate pharmacotherapy for this patient's current symptoms?

Review the following patient summaries describing complex depressive presentations. Match each clinical profile with the most appropriate next step in pharmacologic or somatic management.

Match each patient's clinical presentation with the most appropriate primary or adjunctive treatment modality.

An 18-year-old female university freshman is evaluated at the student health center. Her roommate insisted she be seen because, over the last five weeks, the patient has been skipping classes, crying uncontrollably, and sleeping excessively. The patient reports severe anhedonia, a significant increase in appetite resulting in a 5-kg (11-lb) weight gain, and a sensation of profound physical heaviness in her limbs. Review of her medical records reveals a psychiatric hospitalization eight months ago. During that admission, which lasted 14 days, she exhibited pressured speech, severe psychomotor agitation, an almost complete lack of sleep, and auditory hallucinations commanding her to lead a new global government. She was stabilized and discharged, but subsequently stopped attending follow-up appointments. Three weeks ago, she visited an urgent care clinic for her current depressive symptoms and was started on daily citalopram. She has taken the medication faithfully but reports no improvement in her mood. Vital signs and physical examination are within normal limits. She denies any illicit substance use. Which of the following is the most appropriate pharmacological recommendation at this time?

A concerned spouse brings her 28-year-old husband to the office for evaluation of severe lethargy and persistent low mood. For the past month, the patient has spent most days in bed, stopped attending his weekly basketball games, and experienced a 4-kg (9-lb) weight gain. During the interview, he appears visibly psychomotor retarded. Further history gathering from the spouse reveals a distinct two-week timeframe last summer when the patient slept roughly two hours nightly, exhibited pressured speech, and impulsively purchased an expensive sports car he could not afford. The patient is physically healthy and takes zero prescription or over-the-counter supplements. Which of the following is the most appropriate pharmacotherapy for this patient's current episode?

A 35-year-old patient is diagnosed with severe Major Depressive Disorder without psychotic features. Arrange the following interventions in the standard sequential order of a stepped-care approach for this patient, progressing from the initial evaluation and management to interventions for highly treatment-resistant disease. Assume an inadequate clinical response to each preceding step.