Depression, new or recurrent

#Major Depressive Episode, new
The patient meets criteria for a depressive episode based on PHQ9 of ***. ***Denies suicidal or homicidal ideation. Functional impairment manifested by ***. No personal history of panic attacks, PTSD or manic episodes, significant famhx of bipolar, and no psychotic features. Given new onset, consider secondary causes including cardiac disease, neoplasm (especially oropharyngeal and pancreatic), neurologic disease (including stroke and movement disorders), anemia, diabetes, hypothyroidism, chronic infection (including HIV and HCV), medications (eg, AEDs, steroids, BZDs, BBs, others), and substance use (eg, alcohol, any illicits).
Dx:
- TSH, CBC, BMP, HIV, HCV
- consider Utox, LFTs, HgbA1C, RPR
- defer addn’l cardiac and neoplastic testing for now
- psychiatry referral for suicidality, thought d/o, unclear dx, psychotic features, bipolar, refractory to multiple antidepressants
Non-Pharm Tx:
- psychotherapy referral for CBT and/or supportive therapy
- light therapy (light box vs glasses on Amazon), gradually incresase to 30-45m qd
- aerobic exercise 30m qd x 5 days/week
- biofeedback, yoga, meditation
Pharm Tx: (uptitrate qweekly to qmonthly as tolerated; slow taper off 6-9 months post-remission)
- Medication shared decision making aid: https://depressiondecisionaid.mayoclinic.org/
- start SSRI [escitalopram 5mg qd, then increase to 10-20 mg qd as tolerated] [sertraline (more stimulating, more diarrhea) start 50mg qd, uptitrate by 25-50mg qweekly as tolerated to 200mg qd max]
-- if comorbid panic attacks or inability to tolerate low dose SSRIs, can start with liquid formulation of eg escitalopram 1mg qd and increase by 1mg weekly
- consider starting other classes of meds instead in special circumstances:
-- consider SNRI (esp duloxetine start 30mg qd -> 60-120mg qd max) if chronic pain
-- consider TCA eg nortryptyline (25mg->50-150mg qd) if chronic pain/migraine or amitriptyline (25mg->100-300mg qd) if significant insomnia (caution: TCA lethal in OD)
-- consider buproprion (start 150mg qd -> max 450mg) if desire to avoid weight gain or sexual side effects, or for smoking cessation; (CI: h/o seizures or anxiety)
-- especially if pt naturally inclined, consider adding trial EPA 2g/day and/or SAMe up to 800mg BID (for SAMe, theoretical risk of serotonin syndrome if also taking serotonergic meds)
Resistant/refractory Tx: (unresponsive to 2 therapeutic doses of antidepressant meds)
- trial AD from another class and augment with CBT
- refer to psychiatry
- reassess organic causes, treat SUD/personality disorder/hx trauma
- augment with buproprion/mirtaz or atypical antipsychotic (eg aripiprazole)
- augment with T3, transcranial magnetic stimulation
- consider referral for psychadelic assisted psychotherapy (ketamine is legal, MDMA/psilocybin as part of clinical trials)
- consider electroconvulsive therapy

- f/u 4 weeks

#Major depressive disorder, recurrent
Diagnosed ***year. Has comorbid ***anxiety but no prior manic episodes, suicide attempts or psychosis. Workup for secondary causes unrevealing and denies ongoing substance use. Previous medication trials have included: (med, max dose, duration, response, limiting side effects). Max PHQ9 of *** on ***. Most recent PHQ9 of *** on ***. Plan for today: ***.
- follows with ***therapist, ***psychiatrist (refer if suicidality, thought d/o, unclear dx, psychotic features, bipolar, refractory to multiple antidepressants)
Non-Pharm Tx:
- psychotherapy referral for CBT and/or supportive therapy
- light therapy (light box vs glasses on Amazon), gradually incresase to 30-45m qd
- aerobic exercise 30m qd x 5 days/week
- biofeedback, yoga, meditation
Pharm Tx: (uptitrate qweekly to qmonthly as tolerated; slow taper off 6-9 months post-remission or continue lifelong if >2 episodes of depression)
- start previously effective medication or if none, review medication shared decision making aid: https://depressiondecisionaid.mayoclinic.org/
- start SSRI [escitalopram 5mg qd, then increase to 10-20 mg qd as tolerated] [sertraline (more stimulating, more diarrhea) start 50mg qd, uptitrate by 25-50mg qweekly as tolerated to 200mg qd max]
-- if comorbid panic attacks or inability to tolerate low dose SSRIs, can start with liquid formulation of eg escitalopram 1mg qd and increase by 1mg weekly
- consider starting other classes of meds instead in special circumstances:
-- consider SNRI (esp duloxetine start 30mg qd -> 60-120mg qd max) if chronic pain
-- consider TCA eg nortryptyline (25mg->50-150mg qd) if chronic pain/migraine or amitriptyline (25mg->100-300mg qd) if significant insomnia (caution: TCA lethal in OD)
-- consider buproprion (start 150mg qd -> max 450mg) if desire to avoid weight gain or sexual side effects, or for smoking cessation; (CI: h/o seizures or anxiety)
-- especially if pt naturally inclined, consider adding trial EPA 2g/day and/or SAMe up to 800mg BID (for SAMe, theoretical risk of serotonin syndrome if also taking serotonergic meds)
Resistant/refractory Tx: (unresponsive to 2 therapeutic doses of antidepressant meds)
- trial AD from another class and augment with CBT
- refer to psychiatry
- reassess organic causes, treat SUD/personality disorder/hx trauma
- augment with buproprion/mirtaz or atypical antipsychotic (eg aripiprazole)
- augment with T3, transcranial magnetic stimulation
- consider referral for psychadelic assisted psychotherapy (ketamine is legal, MDMA/psilocybin as part of clinical trials)
- consider electroconvulsive therapy

- f/u 4 weeks