Depressive Disorders

A 32-year-old woman presents to the outpatient clinic with a 2-month history of severely depressed mood. She reports sleeping up to 14 hours a day, an increased appetite with a 5-kg (11-lb) weight gain, and a frequent sensation that her arms and legs are "made of lead." She states that she briefly feels better when her friends visit, but her low mood quickly returns. She has no prior psychiatric history and has never been treated for depression. She tearfully requests an antidepressant medication so she can return to her job as an accountant. Her vital signs and physical examination are unremarkable. Laboratory studies reveal a thyroid-stimulating hormone (TSH) level of 1.5 mU/L (normal: 0.4-4.0 mU/L) and a free T4 at the lower limit of normal. A urine toxicology screen is negative. The physician diagnoses a major depressive episode with atypical features and considers initiating pharmacotherapy. Which of the following is the most appropriate next step in management?

A 28-year-old woman comes to the outpatient clinic for a follow-up appointment. Three weeks ago, she presented with a 2-month history of pervasive sadness, sleeping 14 hours a day, a significantly increased appetite, and a sensation that her arms and legs were "weighed down by lead." She was diagnosed with major depressive disorder and prescribed sertraline. Today, she reports no improvement in her mood or energy. She states, "I have been taking these pills for three weeks and feel exactly the same; I want to just stop taking them."

Upon further questioning, the patient describes an episode three years ago that lasted for two weeks. During that time, she felt "invincible," slept only 2 hours a night without feeling fatigued, spoke so rapidly that friends could not follow her thoughts, and impulsively bought a luxury car she could not afford, which subsequently led to bankruptcy. She has never been hospitalized for psychiatric reasons. Vital signs and physical examination are normal.

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

Accompanied by his roommate, a 21-year-old male college student is brought to the university counseling and psychiatric emergency center. Three weeks ago, he was evaluated at a local walk-in clinic for a two-month history of profound low mood, sleeping up to 14 hours a day, intense cravings for sugary foods, and a sensation that his arms were excessively heavy. At that time, he was diagnosed with major depressive disorder and prescribed fluoxetine. Today, the roommate reports a drastic change in the patient's behavior over the past four days. The patient is currently pacing the examination room, speaking rapidly, and excitedly explaining that he has discovered a theoretical formula that will solve global energy shortages. He mentions he has only slept for two hours over the past two days but feels 'more energetic than ever.' Medical history is otherwise unremarkable. Vital signs are within normal limits. Which of the following is the most appropriate next step in the management of this patient?

A 41-year-old man presents to the clinic with persistent low mood, anhedonia, and insomnia that have significantly impaired his ability to perform his job. He is diagnosed with major depressive disorder (MDD). He has no prior psychiatric history, no history of hypomanic or manic episodes, and no acute suicidal ideation. He expresses a preference for pharmacological treatment. Assuming the patient experiences inadequate clinical improvement at each successive stage of treatment, arrange the following management steps in the correct chronological sequence according to standard stepped-care guidelines for MDD.

For each of the following patients presenting with depressed mood, select the most appropriate initial or next-step intervention based on their specific clinical diagnosis.

A 28-year-old woman is brought to the outpatient clinic by her husband for evaluation of abnormal behavior and low mood. For the past 10 weeks, she has exhibited profound sadness, extreme fatigue, and hypersomnia, often sleeping 14 hours a day. Her husband reports that for the last 6 weeks, she has been responding to unseen stimuli and admits to hearing a persistent voice calling her a "worthless failure."

Two years ago, the patient experienced a 2-week episode of euphoric mood, boundless energy, and rapid speech. During that time, she slept only 2 hours a night and spent the couple's entire savings on unneeded luxury goods, which required a brief psychiatric hospitalization.

She currently takes no medications but asks if she can be started on a combination of a selective serotonin reuptake inhibitor (SSRI) and a monoamine oxidase inhibitor (MAOI), as she read online that this combination is highly effective for severe depression.

Laboratory evaluation shows:
Thyroid-stimulating hormone (TSH): 1.8 µU/mL (Normal: 0.5-5.0 µU/mL)
Free thyroxine (T4): 0.5 ng/dL (Normal: 0.9-1.7 ng/dL)

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

A 35-year-old woman is brought to the clinic by her husband for a follow-up appointment. Two weeks ago, she was prescribed sertraline 50 mg daily for a 2-month history of pervasive sadness, sleeping 12 hours a day, a heavy sensation in her extremities, and a 10-lb weight gain following the sudden death of her father. Today, she reports no improvement in her mood and asks to stop the antidepressant because "two weeks is long enough to know it is not working."

She has a history of a pituitary microadenoma treated with transsphenoidal resection 3 years ago, for which she takes levothyroxine. She also takes a daily over-the-counter St. John's wort supplement. Upon further questioning, her husband notes that during college, the patient had a distinct 6-day period where she slept only 2 hours a night, spoke extremely rapidly, and maxed out her credit cards. She also mentions hearing her deceased father's voice calling her name once a few days ago.

Vital signs are within normal limits. Laboratory studies show:

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

Evaluate the following clinical scenarios of patients presenting with depressive symptoms. Match each patient's clinical presentation with the most suitable treatment modality based on their specific features and comorbidities.

A 68-year-old woman is evaluated in the outpatient clinic for an acute episode of major depressive disorder without psychotic features. Over the course of the next year, her condition proves highly resistant to standard therapies, eventually culminating in severe clinical deterioration. Arrange the following clinical management steps in the correct evidence-based chronological sequence, reflecting the standard escalation of psychiatric care from initial presentation to the eventual onset of life-threatening psychotic depression with severe food refusal.

A 29-year-old woman, G1P0, at 28 weeks gestation is evaluated in the outpatient clinic due to worsening sadness and exhaustion. For the past six weeks, she has felt 'overwhelmed and hopeless,' crying daily. She reports profound despondency that is characteristically worse in the morning, complete loss of appetite, and terminal insomnia, waking up at 3:00 AM and unable to return to sleep. She recently developed an upper respiratory infection and frequently takes over-the-counter dextromethorphan for a persistent cough. Her physical examination is unremarkable. Laboratory studies show a hemoglobin level of $10.8$ g/dL and a mean corpuscular volume of $89$ $\mu$ m $^3$. She asks the physician to prescribe an antidepressant medication to help her cope. Which of the following is the most appropriate next step in management?

A 47-year-old male accountant presents to an outpatient psychiatric clinic with a 3-month history of pervasive sadness, anhedonia, terminal insomnia, profound fatigue, impaired concentration, and a 12-lb (5.4 kg) weight loss. He is diagnosed with a severe episode of major depressive disorder without psychotic features. Over the next 14 months, his condition proves remarkably difficult to treat, eventually culminating in a hospitalization for depressive stupor and mood-congruent delusions.

Arrange the following therapeutic interventions in the most appropriate chronological sequence according to standard stepped-care escalation algorithms for major depressive disorder.

A $23$-year-old woman presents to the outpatient psychiatric clinic with a $2$-month history of profound sadness, fatigue, and social withdrawal. She reports sleeping up to $14$ hours a day and experiencing a strong craving for carbohydrate-rich foods, leading to a $5$-kg ($11$-lb) weight gain. She states her arms and legs frequently feel "so heavy, it is as if my bones have turned to solid stone." Despite her depressed mood, she notes that she felt briefly happy and energized last week when she received a good grade on an exam, though the low mood quickly returned. She also reports occasionally hearing a voice calling her name just as she is drifting off to sleep. She has no chronic medical conditions. Vital signs are within normal limits. Laboratory studies reveal a thyroid-stimulating hormone (TSH) level of $1.8 \text{ \mu U/mL}$ (normal $0.5-5.0 \text{ \mu U/mL}$) and free thyroxine (T4) of $1.2 \text{ ng/dL}$ (normal $0.9-1.7 \text{ ng/dL}$). She is currently not taking any medications. She requests an antidepressant to help her focus on her studies. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man is evaluated in the psychiatric clinic for a six-week history of pervasive sadness, insomnia, low energy, and feelings of worthlessness. He frequently thinks about death but has no active suicidal plan. Vital signs and physical examination are unremarkable. Routine laboratory studies, including thyroid function tests, are within normal limits. During the interview, the patient mentions that in his late twenties, he had a one-week period where he slept only two hours a night, felt extremely energetic, and took out multiple unapproved bank loans for a 'revolutionary' business idea. He was hospitalized during that episode. He is currently taking no medications. What is the most appropriate next step in pharmacological management for this patient?

A 31-year-old woman, G1P1, comes to the outpatient clinic 6 weeks after an uncomplicated vaginal delivery. She is accompanied by her husband, who is concerned about her behavior. For the past 4 weeks, she has experienced profound sadness, frequent crying spells, and a pervasive sense of guilt regarding her parenting. She reports waking up at 3 AM daily and being unable to return to sleep, even when her infant is sleeping. She describes her mood as consistently worse in the mornings and notes no improvement in her mood even when playing with her newborn or when her parents visit. She lacks the energy to perform basic household tasks. She denies suicidal ideation or thoughts of harming the infant. She recalls experiencing a period of "severe depression" in her early twenties that lasted for several months but resolved without treatment. She is currently breastfeeding and takes prenatal vitamins. She does not use tobacco, alcohol, or illicit substances. Vital signs are within normal limits. Which of the following is the most appropriate next step in the evaluation or management of this patient?

A psychiatric consult service is reviewing the charts of four newly evaluated patients who present with prominent depressive symptoms. Each patient's presentation requires a distinct pharmacological or procedural approach. Match each patient's clinical profile with the most appropriate next step in management or treatment strategy.

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

A 32-year-old woman is evaluated in the outpatient psychiatric clinic for worsening mood. She delivered a healthy full-term infant 2 months ago. For the last 3 weeks, she has experienced profound sadness, anhedonia, loss of appetite resulting in a 3-kg (6.6-lb) weight loss, and extreme guilt about being a "terrible mother." For the past week, she reports hearing a persistent, derogatory voice telling her she should "disappear." Her husband notes that 6 years ago, she had a 3-week period where she abruptly quit her job, slept only 2 hours per night but felt fully energetic, exhibited pressured speech, and maxed out their credit cards. This previous episode required a brief psychiatric hospitalization, but she stopped taking her prescribed medications 5 years ago. She currently takes no medications. Vital signs are within normal limits. On examination, she exhibits a blunted affect and psychomotor retardation. Which of the following is the most appropriate next step in management?

Review the clinical vignettes below, representing adult patients currently undergoing psychiatric evaluation for mood symptoms. Map each individual's unique presentation to the most appropriate initial pharmacological or procedural intervention.

A 50-year-old woman is diagnosed with major depressive disorder following a period of persistent low mood and anhedonia. Over the next year, her condition progressively worsens despite various treatment attempts, culminating in a state of severe melancholia characterized by a life-threatening refusal to eat and drink. Arrange the following clinical management steps in the correct chronological sequence, representing a standard stepped-care escalation for this patient's evolving clinical condition.

A 28-year-old man presents to a primary care clinic with a 2-month history of worsening mood, severe fatigue, and lack of motivation. He reports sleeping up to 12 hours a day but still feeling exhausted upon waking. Additionally, he has experienced a significant increase in appetite, resulting in a 6 kg (13.2 lb) weight gain over the past month. He describes a pervasive sensation of extreme heaviness in his arms and legs, making it difficult to get out of bed. His past medical history is notable for a severe depressive episode at age 20. At that time, he was prescribed a medication that he discontinued after 3 weeks because it made him feel "too wired and agitated." He is currently not taking any medications. Vital signs and physical examination are unremarkable. The physician is considering starting an antidepressant. Which of the following is the most appropriate next step in the management of this patient?