One-liner#

Screen for and manage major depressive disorder in primary care using validated tools, first-line antidepressants, and appropriate safety assessment, while recognizing when to refer to psychiatry.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Active suicidal ideation with plan and intent → ED for psychiatric evaluation
• Homicidal ideation with specific target → ED; duty to warn
• Psychotic symptoms (hallucinations, delusions) → ED or urgent psychiatry
• Unable to care for self (not eating, not drinking, severe neglect) → ED
• Recent suicide attempt → ED

Crisis resources: 988 Suicide & Crisis Lifeline (call or text 988); Crisis Text Line (text HOME to 741741)

Urgent (not ED, but same-day/next-day):

• Suicidal ideation without plan but with risk factors (prior attempt, access to means)
• Severe functional impairment (can’t work, can’t care for children)
• New onset mania symptoms (may be bipolar—do not start antidepressant alone)

Key history#

PHQ-9 (administer at every visit):

• Score 0-4: minimal
• Score 5-9: mild
• Score 10-14: moderate
• Score 15-19: moderately severe
• Score 20-27: severe

Core symptoms (need ≥1 for diagnosis):

• Depressed mood most of the day, nearly every day
• Anhedonia (loss of interest/pleasure)

Associated symptoms:

• Sleep changes (insomnia or hypersomnia)
• Appetite/weight changes
• Fatigue/low energy
• Psychomotor agitation or retardation
• Worthlessness or excessive guilt
• Difficulty concentrating
• Thoughts of death or suicide

Duration and course:

• Symptoms ≥2 weeks for MDD diagnosis
• First episode vs recurrent
• Previous episodes: timing, treatment, response
• Seasonal pattern

Safety assessment (EVERY visit):

• “Are you having thoughts of hurting yourself or ending your life?”
• If yes: frequency, plan, intent, access to means
• Prior suicide attempts (strongest predictor)
• Protective factors (reasons for living, social support)

Functional impact:

• Work/school performance
• Relationships
• Self-care
• Childcare responsibilities

Rule out secondary causes:

• Hypothyroidism
• Anemia
• Vitamin B12/folate deficiency
• Substance use (alcohol, cannabis, opioids)
• Medications (beta-blockers, steroids, interferon)
• Medical illness (cancer, stroke, Parkinson’s, chronic pain)

Screen for bipolar (before starting antidepressant):

• Prior manic/hypomanic episodes
• Family history of bipolar
• Early age of onset (<25)
• Multiple failed antidepressant trials
• Antidepressant-induced mania
• If suspected: do NOT start antidepressant alone → psychiatry referral

Comorbidities:

• Anxiety (very common; ~60% comorbid)
• Substance use
• Chronic pain
• Medical illness

Focused exam#

Mental status exam:

• Appearance: grooming, hygiene, psychomotor changes
• Behavior: eye contact, engagement, agitation/retardation
• Speech: rate, volume, tone (often slow, soft, monotone)
• Mood: patient’s description (“sad,” “empty,” “numb”)
• Affect: flat, constricted, tearful, congruent with mood
• Thought content: hopelessness, worthlessness, guilt, suicidal ideation
• Cognition: concentration, memory (depression can cause pseudodementia)
• Insight/judgment

Physical exam (to rule out medical causes):

• Vital signs
• Thyroid exam
• Neurologic exam if cognitive complaints

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Routine for new depression diagnosis:

Consider based on presentation:

When NOT to order extensive workup:

• Classic MDD presentation in otherwise healthy patient
• No red flags for medical cause
• PHQ-9 confirms depression

Initial management#

Mild depression (PHQ-9 5-9):

• Psychotherapy alone may be sufficient
• Lifestyle: exercise, sleep hygiene, social activation
• Close follow-up; start medication if not improving

Moderate to severe depression (PHQ-9 ≥10):

• Antidepressant medication recommended
• Combination of medication + psychotherapy most effective
• Start SSRI as first-line

Medication selection principles:

• SSRIs are first-line (efficacy, tolerability, safety)
• Choose based on side effect profile and patient factors
• Prior response: use what worked before
• Family history of response can guide selection
• Consider comorbidities (anxiety, pain, insomnia)

Management by diagnosis#

Major depressive disorder#

Education:

• Depression is a medical illness, not a character flaw
• Treatment works for most people
• Medications take 4-6 weeks for full effect
• May feel worse before better (first 1-2 weeks)
• Do not stop medication abruptly

Treatment:

SSRI side effects to counsel:

• GI upset (usually improves in 1-2 weeks)
• Sexual dysfunction (may persist; consider bupropion if problematic)
• Initial anxiety/activation (warn patient; usually transient)
• Weight changes (usually modest)
• Discontinuation syndrome (taper, don’t stop abruptly)

Black box warning (patients <25 years):

• Increased risk of suicidal thinking/behavior in children, adolescents, and young adults
• Counsel patient and family; close monitoring in first 4 weeks
• Risk of untreated depression generally outweighs medication risk
• Document discussion in chart

Renal dosing: Most antidepressants do not require dose adjustment in CKD. Exceptions: duloxetine avoid if CrCl <30; venlafaxine reduce dose by 25-50% if CrCl <30.

Elderly considerations:

• Start at half the usual dose
• Escitalopram max 10 mg in patients >65
• Avoid paroxetine (anticholinergic, Beers list)
• Mirtazapine good choice if insomnia/poor appetite
• Monitor for hyponatremia (SIADH), especially with SSRIs

Pregnancy/breastfeeding:

• Untreated depression carries risks; weigh benefits vs risks
• Sertraline preferred in pregnancy (most safety data)
• Paroxetine: avoid in first trimester (cardiac defects)
• Bupropion: reasonable alternative
• Third trimester SSRI exposure: neonatal adaptation syndrome (usually mild, self-limited)
• Breastfeeding: sertraline preferred (low milk levels)
• Refer to psychiatry or MFM for complex cases

How to taper antidepressants:

• Reduce dose by 25% every 2-4 weeks
• Slower taper for paroxetine, venlafaxine (higher discontinuation risk)
• If discontinuation symptoms: return to previous dose, then taper more slowly
• Fluoxetine: long half-life, often can stop without taper

If first SSRI fails (adequate trial = 6-8 weeks at therapeutic dose):

1. Optimize dose (increase to max tolerated)
2. Switch to different SSRI or SNRI
3. Augment (after 2 failed trials): add bupropion, buspirone, or atypical antipsychotic
4. Refer to psychiatry if 2+ adequate trials fail

Follow-up: 2-4 weeks after starting/changing medication; then monthly until stable; then every 3 months.

Persistent depressive disorder (dysthymia)#

Education:

• Chronic, low-grade depression lasting ≥2 years
• Often feels “normal” to patient
• Treatment can significantly improve quality of life
• May take longer to respond than acute MDD

Treatment:

• Same medications as MDD
• Psychotherapy (especially CBT, CBASP) particularly helpful
• Combination therapy recommended
• May need longer treatment duration

Follow-up: Monthly until stable; long-term maintenance often needed.

Adjustment disorder with depressed mood#

Education:

• Reaction to identifiable stressor
• Usually resolves within 6 months of stressor ending
• Not the same as MDD

Treatment:

• Supportive counseling/psychotherapy first-line
• Medication usually not needed
• If symptoms severe or prolonged, treat as MDD

Follow-up: 4-6 weeks; reassess if not improving.

Depression with comorbid anxiety#

Education:

• Very common (60%+ of depression has comorbid anxiety)
• Both conditions need treatment
• SSRIs treat both

Treatment:

• SSRI first-line (treats both)
• Start at lower dose (anxious patients sensitive to activation)
• Sertraline, escitalopram, or paroxetine preferred
• Avoid bupropion (can worsen anxiety)
• Short-term benzodiazepine bridge controversial; avoid if possible

Follow-up: 2 weeks initially (monitor for activation); then as for MDD.

Treatment-resistant depression#

Definition: Failed ≥2 adequate antidepressant trials

PCP role:

• Confirm adequate trials (dose, duration, adherence)
• Rule out bipolar, substance use, medical causes
• Consider augmentation strategies
• Refer to psychiatry

Augmentation options (often psychiatry-initiated):

• Add bupropion to SSRI/SNRI (bupropion XL 150 mg daily, can increase to 300 mg)
• Add buspirone (start 5 mg TID, titrate to 15-30 mg TID)
• Add atypical antipsychotic (aripiprazole 2-5 mg daily, quetiapine 50-150 mg at bedtime, brexpiprazole 0.5-2 mg daily)
• Lithium augmentation (psychiatry)
• Thyroid augmentation (psychiatry)

Other options (psychiatry):

• TMS (transcranial magnetic stimulation)
• Esketamine nasal spray
• ECT for severe, refractory cases

Follow-up#

Initial treatment:

• 2-4 weeks after starting medication (assess tolerability, safety)
• 4-6 weeks (assess early response)
• Monthly until remission

Maintenance:

• Every 3 months once stable
• PHQ-9 at every visit
• Safety assessment at every visit

Duration of treatment:

• First episode: continue 6-12 months after remission
• Recurrent episodes: consider indefinite maintenance
• Taper slowly when discontinuing (over weeks to months)

Return precautions:

• Worsening depression
• New or worsening suicidal thoughts
• Side effects that are intolerable
• Symptoms of mania (decreased sleep, racing thoughts, impulsivity)
• Not improving after 6-8 weeks

Patient instructions#

• Depression is a medical condition, like diabetes or high blood pressure. It’s not your fault.
• The medication takes 4-6 weeks to work fully. Don’t give up if you don’t feel better right away.
• You may feel a bit more anxious or jittery in the first week or two. This usually goes away.
• Take your medication every day, even when you start feeling better. Stopping suddenly can cause problems.
• Call us right away if you have thoughts of hurting yourself or if you feel much worse.
• Try to keep a regular sleep schedule, get some exercise, and stay connected with people you trust.
• Therapy combined with medication works better than either alone. Consider seeing a counselor.

Smartphrase snippets#

.DEPRESSIONMILD PHQ-9 score [X] consistent with mild depression. Safety assessment negative for suicidal ideation. Discussed treatment options including psychotherapy and lifestyle modifications. Patient prefers to [start medication / try therapy first / watchful waiting]. [If medication: Starting sertraline 50 mg daily.] Follow-up in 4 weeks. Return precautions reviewed including worsening symptoms or suicidal thoughts.

.DEPRESSIONMOD PHQ-9 score [X] consistent with moderate major depressive disorder. Safety assessment: [no SI / passive SI without plan or intent]. TSH and CBC ordered to rule out medical causes. Starting [sertraline 50 mg / escitalopram 10 mg] daily. Discussed that medication takes 4-6 weeks for full effect and may cause initial GI upset or anxiety. Psychotherapy referral placed. Follow-up in 2-4 weeks. Patient instructed to call or go to ED if suicidal thoughts worsen.

.DEPRESSIONSEVERE PHQ-9 score [X] consistent with severe major depressive disorder. Safety assessment: [document SI status, plan, intent, access to means, protective factors]. [If safe to manage outpatient:] Starting [medication] with close follow-up. Psychotherapy referral placed. Safety plan reviewed. Emergency contact identified. Follow-up in 1-2 weeks. Patient and [family member/support person] instructed to call 988 or go to ED if suicidal thoughts worsen or patient unable to stay safe.

.DEPRESSIONFOLLOWUP Depression follow-up. PHQ-9 today: [X] (previous: [Y]). [Improved / stable / worsened]. Safety assessment negative. Current medication: [drug, dose]. [Tolerating well / side effects: X]. Plan: [continue current regimen / increase dose / switch medication / add augmentation / refer to psychiatry]. Follow-up in [timeframe].

Related pages#

• Major Depressive Disorder (problem) — comprehensive ongoing management of MDD
• Anxiety — often comorbid; similar treatment
• Insomnia — sleep disturbance in depression
• Fatigue — depression as cause of fatigue
• Substance use — screen for comorbid use
• Adult ADHD — can mimic or coexist with depression
• Cognitive decline — pseudodementia vs dementia