Depressive Disorders

During a routine visit to an outpatient clinic, a 29-year-old woman reports a 2-month history of persistent sadness, tearfulness, and profound fatigue. She states she has lost interest in reading and hiking, activities she previously enjoyed every weekend. The patient notes she has been waking up at 3 AM daily and is unable to fall back asleep. She has lost 4 kg (8.8 lb) over this period without actively dieting. She denies any substance use or suicidal ideation. She has no significant past medical history and currently takes no medications. Her physical examination is unremarkable. The patient requests to be started on a medication to help her mood, noting that a family member had significant improvement with fluoxetine. Which of the following is the most appropriate next step in the clinical evaluation of this patient?

A 58-year-old woman is evaluated in the psychiatric clinic for a severe depressive episode characterized by profound sadness, anhedonia, early morning awakening, and significant weight loss. Over the course of the following year, her major depressive disorder proves difficult to manage, requiring a progressive escalation of her treatment plan due to varying degrees of treatment resistance. Her course ultimately culminates in a severe decompensation requiring urgent intervention. Arrange the following therapeutic steps in the most appropriate chronological sequence according to standard evidence-based treatment algorithms for major depressive disorder, from her initial presentation to the management of her final life-threatening deterioration.

A 42-year-old man presents to the psychiatric clinic for the management of a newly diagnosed major depressive disorder (MDD). Over the next 18 months, his clinical course is characterized by significant treatment resistance, eventually leading to a severe exacerbation with psychotic features and food refusal. Arrange the following therapeutic interventions in the correct chronological order according to standard stepped-care pharmacologic and somatic treatment guidelines for MDD, starting from his initial presentation to his most severe exacerbation.

A 36-year-old woman presents to the primary care clinic reporting a 5-week history of profound sadness, early morning awakening, decreased appetite, and difficulty concentrating at work. She states she has never felt this way before and denies any current suicidal ideation, hallucinations, or delusions. Her medical history is unremarkable, and she takes no medications. The physician determines she is experiencing a major depressive episode and considers initiating fluoxetine therapy. Which of the following is the most appropriate next step in the clinical care of this patient?

A 67-year-old man is evaluated by the consultation-liaison psychiatry team on the medical floor. He was admitted one week ago for a non-ST-elevation myocardial infarction and subsequently developed a complicated soft-tissue infection at the catheter insertion site, for which he is currently receiving intravenous linezolid. The nursing staff reports that the patient has been increasingly withdrawn, tearful, and refusing to participate in physical therapy. During the interview, the patient is fully oriented and demonstrates intact decision-making capacity. He reports a two-month history of a profoundly depressed mood, pervasive anhedonia, early morning awakenings, a 5-kg (11-lb) weight loss, and hearing a voice repeatedly telling him he is a "total failure." He states, "I just have no energy left to fight, but I definitely do not want any sort of shock treatments." His wife, who is present, privately tells the physician, "He doesn't know what he's saying. I give you full permission to do electroconvulsive therapy if it will fix this." Review of his past medical history reveals an episode at age 26 when he was hospitalized for a week after staying awake for five consecutive days and recklessly spending his life savings on an impulsive business venture. Which of the following is the most appropriate next step in the psychiatric management of this patient?

Match each clinical presentation of a depressive disorder to the most appropriate next step in management or targeted therapy.

A son brings his 68-year-old mother to the geriatric psychiatry clinic due to a 6-week history of profound lethargy, worsening sadness, and uncharacteristic behavior. He reports that she now spends most of her day in bed and has lost 4.5 kg (10 lb) due to a near-total loss of appetite. During the interview, the patient repeatedly states that her internal organs are 'turning to dust' as a punishment for her past sins, and she mentions hearing a male voice that agrees with her. Her medical history includes severe osteoarthritis, for which she takes scheduled tramadol and acetaminophen. A review of her past psychiatric history reveals that at age 40, she experienced a 3-week episode characterized by a severely decreased need for sleep, rapid and pressured speech, and grandiose plans to start a nationwide business, which resulted in an involuntary psychiatric hospitalization. She was treated with medication at the time but discontinued it shortly after discharge and has not taken any psychiatric medications since. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A 32-year-old woman is evaluated in the psychiatry clinic for ongoing management of major depressive disorder. She initially presented two years ago with a 3-month history of pervasive sadness, anhedonia, significant weight loss, and severe insomnia leading to functional impairment at work. Over the course of her illness, she has required progressive escalation of her treatment regimen due to inadequate responses. Arrange the following therapeutic interventions in the generally accepted chronological sequence that her physician would have followed, from initial diagnosis to the management of severe, treatment-resistant symptoms.

A 31-year-old accountant visits the family medicine clinic accompanied by his partner. He reports a 5-week history of profound sadness, decreased energy, and difficulty concentrating. He states that he sleeps up to 14 hours a day and has gained 6 kg (13 lbs) over the past month. He describes a persistent sensation that his arms and legs are "weighed down by lead." His partner notes that his mood occasionally brightens for a few hours when they go out to his favorite restaurant, but he quickly reverts to feeling depressed. He has missed several days of work. He has no significant past medical history. Family history is notable for a mother who was hospitalized multiple times for erratic behavior and severe mood swings. Physical examination and basic laboratory studies, including thyroid function tests, are within normal limits. The physician determines that the patient is experiencing a major depressive episode. Which of the following is the most critical next step in management prior to initiating pharmacotherapy?

A $28$-year-old woman, who is at $10$ weeks gestation in her first pregnancy, presents to the psychiatric clinic with a $4$-week history of overwhelming sadness, excessive sleeping up to $14\text{ hours}$ a day, and a sensation that her arms and legs are "weighed down by lead." She experiences daily crying spells and profound guilt over her lack of excitement regarding the pregnancy. She mentions that her primary care physician prescribed fluoxetine $3$ weeks ago, but she discontinued it yesterday because she felt it was completely ineffective. Vital signs are within normal limits. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $0.2\text{ \mu U/mL}$ (normal non-pregnant: $0.5$-$5.0\text{ \mu U/mL}$) and a free thyroxine (T4) level of $1.1\text{ ng/dL}$ (normal: $0.9$-$1.7\text{ ng/dL}$). Which of the following is the most appropriate next step in the management of this patient?

A 24-year-old medical student is diagnosed with a first episode of major depressive disorder. After ruling out any history of mania or hypomania, the physician prescribes a selective serotonin reuptake inhibitor (SSRI). The physician provides comprehensive anticipatory guidance regarding the expected treatment timeline. Arrange the following clinical events in the standard chronological order of their expected occurrence during a successful, uncomplicated course of SSRI therapy.

A $65$-year-old retired firefighter is brought to the outpatient clinic by his husband. For the past $5$ weeks, the patient has experienced a pervasive low mood, early morning awakenings, and a lack of interest in his previously beloved woodworking projects. He has lost $5$ kg ($11$ lb) during this period. The symptoms started roughly $2$ weeks after he suffered an uncomplicated myocardial infarction. He says, "My life is essentially over; there is nothing to look forward to." Past medical history includes hypertension and the recent myocardial infarction. Thirty-five years ago, he experienced an episode of paranoia and auditory hallucinations that lasted for $14$ days and resolved completely without any subsequent psychotic symptoms. Current medications include aspirin, ticagrelor, metoprolol, rosuvastatin, and linezolid, which was started $4$ days ago for a methicillin-resistant Staphylococcus aureus skin infection. The patient's advance directive designates his sister as his healthcare proxy. He is alert, oriented, and demonstrates a clear understanding of his diagnosis and treatment options. His husband pulls the physician aside and says, "He is too sad to think straight; I am his spouse, so I authorize you to prescribe whatever strong medication he needs right now." The physician concludes that the patient is experiencing a major depressive episode. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation with the most appropriate initial pharmacological intervention.

A university student, aged 22, presents to the campus health center complaining of an 8-week history of profound melancholy, excessive sleepiness, and a complete inability to concentrate. She explains that she has stopped attending her lectures and feels devoid of any motivation. Review of her medical records reveals a prior psychiatric admission two years ago; during that time, she remained awake for six consecutive days, exhibited grandiose delusions about leading the university, and engaged in highly disruptive activities on campus before being hospitalized. She is currently not taking any medications. Recent thyroid function tests show a thyroid-stimulating hormone (TSH) level of $2.5 \mu\text{U/mL}$ (normal: $0.4-4.0 \mu\text{U/mL}$) and a free thyroxine ($T_4$) level of $0.9 \text{ ng/dL}$ (normal: $0.8-1.8 \text{ ng/dL}$). She insists on being prescribed a medication to lift her mood so she can return to her studies. Which of the following is the most appropriate management plan for this patient?

A 45-year-old woman is diagnosed with severe major depressive disorder without psychotic features. Place the following therapeutic interventions in the most appropriate chronological sequence of standard stepped-care escalation, assuming the patient exhibits an inadequate or partial response at each preceding step.

For each of the following clinical scenarios involving a depressive presentation or its treatment, select the most appropriate next step in management.