Eduovisual
Behavioral Health
Persistent depressive disorder (dysthymia)
— Must include ≥2 of: poor appetite/overeating, insomnia/hypersomnia, low energy, low self-esteem, poor concentration, hopelessness.
— During the 2-year window, the patient is never symptom-free for >2 consecutive months.
— Adult presenting to primary care with years of "always been a low-energy person," "gloomy," "glass-half-empty," chronic low self-worth, often functioning at work but joyless.
— Frequent somatic complaints (fatigue, GI, headaches) without clear medical etiology — high utilizers of outpatient visits.
— Comorbid anxiety, substance use, personality pathology (cluster C), or chronic medical illness (diabetes, CAD, hypothyroidism).
Board pearl: A patient who says "I've felt this way as long as I can remember" with ≥2 years of low-grade depressive symptoms is PDD until proven otherwise — screen with PHQ-9 and ask about superimposed MDD episodes ("double depression"), which occurs in 75% over the lifetime and worsens prognosis.
— Duration: ≥2 years continuous (≥1 in youth); ask "When was the last time you felt genuinely happy for more than a couple of months?"
— Symptom-free intervals: Must be ≤2 months at a time.
— Functional level: Often "walking wounded" — works, parents, but lacks pleasure, ambition, intimacy.
— Family history of mood disorders, substance use, suicide.
— Medical screen: hypothyroidism, anemia, OSA, vitamin D/B12 deficiency, chronic pain, steroid/interferon use.
— Substance use: alcohol and cannabis commonly mask or mimic PDD.
— Trauma/ACEs: strong association with childhood adversity.
— Cognitive symptoms (hopelessness, low self-esteem, indecisiveness) dominate.
— Neurovegetative symptoms (appetite, sleep, energy) are present but less severe than in MDD.
— Less anhedonia and psychomotor change than full MDD.
— PHQ-2 → PHQ-9 at every annual visit (USPSTF Grade B in adults).
— Track scores longitudinally; PDD often hovers PHQ-9 = 8–14.
Step 3 management: When PHQ-2 is positive, complete PHQ-9, screen for bipolarity (MDQ), suicidality (C-SSRS), substance use (AUDIT), and anxiety (GAD-7) before initiating antidepressants — missing bipolar history is a classic distractor.
— Vitals: bradycardia or weight gain (hypothyroidism); tachycardia/tremor (hyperthyroidism, stimulant use, withdrawal).
— Thyroid: palpate for goiter, nodules.
— Skin: dry, coarse (hypothyroid); track marks, stigmata of alcohol use.
— Neuro: focal deficits suggest stroke, MS, neurodegenerative disease causing secondary depression.
— BMI and waist circumference — metabolic syndrome risk is elevated and antidepressants may worsen it.
— Appearance: often well-groomed, may appear older than stated age, fatigued.
— Behavior: cooperative, mild psychomotor slowing possible but less prominent than MDD.
— Speech: normal rate, sometimes low volume.
— Mood: "down," "blah," "empty"; Affect: constricted, dysphoric, reactive.
— Thought process: linear, goal-directed.
— Thought content: pessimism, low self-worth, hopelessness; assess SI/HI explicitly.
— Perception: no hallucinations (if present, reconsider diagnosis).
— Cognition: intact orientation; mild subjective concentration problems; screen elderly with MoCA to rule out pseudodementia vs. neurocognitive disorder.
— Insight/judgment: typically preserved.
Key distinction: Florid psychomotor retardation, mood-congruent psychosis, or catatonia points away from PDD and toward severe MDD with psychotic features — escalate care and consider ECT evaluation rather than chronic outpatient SSRI titration.
— TSH ± free T4 — hypothyroidism is the single most common medical mimic; subclinical hypothyroidism can present as chronic low mood.
— CBC — anemia, occult infection, alcohol-related macrocytosis (MCV >100).
— CMP — hepatic/renal baseline before SSRI/SNRI; hyponatremia risk on SSRI in elderly.
— Vitamin B12 and 25-OH vitamin D — deficiencies common; correlate with mood and fatigue.
— HbA1c and fasting lipids — establish metabolic baseline; some antidepressants (mirtazapine, paroxetine) worsen weight/lipids.
— Urine drug screen when substance use suspected.
— HIV, RPR, hepatitis C if risk factors — neuropsychiatric manifestations.
— Baseline ECG before citalopram (FDA limit 40 mg/day; 20 mg in elderly/CYP2C19 poor metabolizers due to QT prolongation) and TCAs.
— Useful in elderly or those on other QT-prolonging meds.
— Pregnancy test (β-hCG) in reproductive-age women before starting pharmacotherapy.
— Iron studies/ferritin if fatigue dominant.
— Cortisol/ACTH only if Cushing's features.
— OSA screen (STOP-BANG) in obese, snoring patients with hypersomnia.
Board pearl: A patient with 3 years of "depression" that hasn't responded to two SSRIs and has TSH 12 with mildly elevated cholesterol — treat the hypothyroidism first; mood often improves within weeks of euthyroid state, sometimes obviating antidepressants entirely.
— DSM-5-TR criteria applied via clinical interview remain the gold standard; structured tools (SCID-5, MINI) used in research but not required for Step 3.
— PHQ-9 tracks severity longitudinally; <5 remission, 5–9 mild, 10–14 moderate, 15–19 moderately severe, ≥20 severe.
— Hamilton Depression Rating Scale (HAM-D) and Montgomery-Åsberg (MADRS) are clinician-administered alternatives.
— Mood Disorder Questionnaire (MDQ) or careful history for past hypomania/mania.
— Red flags for bipolarity: early-onset depression, family history of bipolar, postpartum episodes, antidepressant-induced activation, hypersomnia + hyperphagia (atypical features).
— Starting an SSRI in undiagnosed bipolar can precipitate mania — a frequent Step 3 trap.
— GAD-7 for anxiety (50–75% comorbid).
— AUDIT-C, DAST-10 for substance use.
— PCL-5 for PTSD.
— Personality assessment — cluster C traits (avoidant, dependent, obsessive-compulsive) common and influence psychotherapy choice.
— MoCA or MMSE to differentiate pseudodementia of depression (improves with treatment) from neurocognitive disorder.
— Consider brain MRI in late-onset depression (>60) with cognitive complaints — vascular depression, NPH, frontotemporal pathology.
— Polysomnography if OSA features; treating OSA can dramatically improve refractory mood symptoms.
Step 3 management: Document the DSM-5-TR criteria explicitly in your assessment, list comorbidities, and stage severity with a PHQ-9 score — this drives whether you start with psychotherapy alone (mild), combination therapy (moderate), or expedited pharmacotherapy plus referral (severe or with SI).
— Mild (PHQ-9 5–9): psychotherapy alone is reasonable first-line; shared decision-making about medication.
— Moderate (PHQ-9 10–14): combined psychotherapy + pharmacotherapy is most effective for chronic depression (per landmark CBASP/Keller trial data).
— Moderate-severe to severe (≥15): pharmacotherapy is essential; psychotherapy adjunctive.
— With active SI, psychosis, or inability to function: urgent psychiatric referral, consider inpatient.
— Chronic depression responds substantially better to combined treatment than to either modality alone — combined response rates ~73% vs. ~48% monotherapy.
— Psychotherapy targets entrenched cognitive distortions and interpersonal patterns built over years.
— CBASP (Cognitive Behavioral Analysis System of Psychotherapy) — purpose-built for chronic depression.
— CBT and IPT (Interpersonal Therapy) are evidence-based alternatives.
— Behavioral activation for low-motivation patients.
— Discuss expected onset (4–6 weeks for meds, 8–12 sessions for therapy), side effects, duration (≥2 years given chronicity), cost, and patient preference.
— Set measurement-based care expectations: PHQ-9 every 2–4 weeks initially.
— Aerobic exercise ≥150 min/week — antidepressant effect size moderate.
— Sleep hygiene, alcohol moderation, light exposure, social engagement.
Step 3 management: For a stable outpatient with moderate PDD, the highest-yield answer is almost always "start an SSRI AND refer for CBT/CBASP" — choosing either alone is the distractor when both are offered.
— Sertraline 25–50 mg → titrate to 50–200 mg/day. Favored in cardiac comorbidity, pregnancy, breastfeeding.
— Escitalopram 5–10 mg → 10–20 mg/day. Clean profile, fewer drug interactions.
— Fluoxetine 10–20 mg → 20–80 mg/day. Long half-life forgives missed doses; activating — good for low-energy presentations.
— Citalopram 10–20 mg → max 40 mg/day (20 mg if >60 yo or CYP2C19 poor metabolizer) — QT caution.
— Duloxetine 30–60 mg/day — useful with comorbid neuropathic pain, fibromyalgia, stress incontinence.
— Venlafaxine XR 37.5–225 mg/day — monitor BP at higher doses (dose-dependent hypertension).
— Bupropion 150–300 mg XL — no sexual dysfunction, weight-neutral, helps smoking cessation; avoid in seizure disorder, active eating disorder.
— Mirtazapine 15–45 mg qhs — sedating, increases appetite; ideal for insomnia + poor appetite + weight loss in elderly.
— Reassess at 2 weeks (tolerability), 4–6 weeks (early response), 8–12 weeks (full response). Adequate trial = max tolerated dose × 6–8 weeks.
— Response = ≥50% PHQ-9 reduction; remission = PHQ-9 <5.
— Warn about initial GI side effects, sexual dysfunction, weight changes, sleep effects.
— FDA black-box warning: increased suicidality in patients <25; arrange follow-up within 1–2 weeks of initiation.
— Avoid abrupt discontinuation — SSRI discontinuation syndrome (flu-like, dizziness, "brain zaps"), worst with paroxetine and venlafaxine.
Board pearl: For chronic depression, continue antidepressants for ≥2 years after remission, often indefinitely — recurrence rates approach 70% within 5 years off medication in PDD. This contrasts with first-episode MDD (6–12 months continuation).
— Step 1: Optimize dose to maximum tolerated for full 6–8 weeks.
— Step 2: Switch within class (e.g., sertraline → escitalopram) or across class (SSRI → SNRI or bupropion). Cross-taper to avoid serotonin syndrome and discontinuation symptoms.
— Step 3: Augment rather than switch when partial response present.
— Aripiprazole 2–15 mg, brexpiprazole 1–3 mg, or quetiapine XR 150–300 mg — FDA-approved adjuncts for MDD; monitor metabolic parameters, EPS, akathisia, tardive dyskinesia.
— Bupropion added to SSRI — combats sexual side effects, augments efficacy.
— Mirtazapine added to SSRI/SNRI ("California rocket fuel" with venlafaxine).
— Lithium 600–900 mg with level 0.6–0.8 — classic augmentation; check renal/thyroid baseline.
— T3 (liothyronine) 25–50 mcg — STAR*D-supported augmentation.
— Esketamine intranasal (SPRAVATO) — REMS program, 2-hour monitoring post-dose; for adults with TRD on oral antidepressant.
— IV ketamine off-label.
— ECT — gold standard for severe, psychotic, catatonic, or pregnancy-complicated depression.
— rTMS — outpatient, non-anesthesia option; avoid in seizure history, metal implants near coil.
— MAOIs (phenelzine, tranylcypromine) — effective but dietary tyramine restrictions and serotonin syndrome risk; require 14-day washout from SSRIs (5 weeks for fluoxetine).
— Serotonin syndrome: triad of mental status change, autonomic instability, neuromuscular hyperactivity (clonus, hyperreflexia) — discontinue agents, supportive care, cyproheptadine if severe.
Step 3 management: A patient on sertraline 200 mg with PHQ-9 dropping 15→9 (partial response) — augment with aripiprazole or bupropion, don't switch. Switch only when there's been minimal response (<25% improvement).
— Late-onset depression (>60) more often reflects vascular depression, neurodegeneration, or medical illness — evaluate cognition (MoCA), consider MRI for white matter disease, and rule out medications (β-blockers, steroids, opioids, anticholinergics).
— Pseudodementia: depression mimicking dementia — patients highlight memory deficits ("I can't remember anything"), perform inconsistently, and improve with antidepressant treatment.
— Preferred: sertraline, escitalopram, mirtazapine (good for insomnia + poor appetite + weight loss).
— Avoid or use cautiously (Beers criteria):
— Paroxetine — anticholinergic, sedating, falls.
— TCAs — anticholinergic, orthostasis, cardiac conduction.
— Citalopram >20 mg — QT prolongation.
— Start at half the usual adult dose; titrate slowly ("start low, go slow").
— Hyponatremia/SIADH — check basic metabolic panel at 2 and 4 weeks, especially with concurrent thiazides; risk highest in first month.
— Falls and fractures — SSRIs increase fall risk; review home safety.
— GI bleeding — additive risk with NSAIDs/anticoagulants; consider PPI cover if dual therapy unavoidable.
— QT prolongation — baseline ECG with citalopram, escitalopram at higher doses.
— Sertraline, fluoxetine, mirtazapine — minimal dose adjustment.
— Duloxetine: avoid if CrCl <30 mL/min.
— Venlafaxine — reduce dose 25–50% if CrCl <70.
— Paroxetine — reduce in severe renal impairment.
— Duloxetine contraindicated in chronic liver disease/heavy alcohol use (hepatotoxicity).
— Reduce dose by 50% for most SSRIs in moderate-severe cirrhosis; sertraline often preferred.
Board pearl: Elderly woman on HCTZ started on sertraline; 3 weeks later confused with Na 124 — SSRI-induced SIADH. Hold SSRI, fluid restrict, and choose bupropion or mirtazapine (lower hyponatremia risk) on rechallenge.
— Untreated depression itself carries fetal risk (preterm birth, low birth weight, postpartum depression, impaired bonding). Do not reflexively stop antidepressants at pregnancy diagnosis.
— Preferred SSRIs: sertraline (lowest breast milk transfer, robust safety data) and citalopram/escitalopram.
— Avoid paroxetine — associated with cardiac malformations (especially septal defects); FDA Category D historically.
— Third-trimester SSRI exposure can cause neonatal adaptation syndrome (transient jitteriness, feeding difficulty, respiratory distress) and possible small absolute risk of persistent pulmonary hypertension of the newborn (PPHN) — do not abruptly stop; manage neonate supportively.
— Shared decision-making with OB and psychiatry; document risk-benefit conversation.
— Screen with Edinburgh Postnatal Depression Scale (EPDS) at well-baby visits and 6-week postpartum visit.
— Brexanolone IV (60-hour infusion, REMS) and zuranolone PO (14-day course) approved specifically for postpartum depression — board-relevant novel agents.
— Sertraline is first-line oral agent during breastfeeding.
— Criteria: ≥1 year duration; mood may be irritable rather than sad.
— Always screen for bullying, abuse, learning disability, substance use, and suicide risk (leading cause of death in adolescents).
— First-line psychotherapy: CBT, IPT-A.
— FDA-approved pediatric antidepressants for depression: fluoxetine (≥8 yo) and escitalopram (≥12 yo).
— Black-box warning: increased suicidal ideation/behavior in <25 yo — weekly visits ×4, then biweekly ×4, then monthly.
Step 3 management: Pregnant patient on paroxetine with stable mood — switch to sertraline before conception or in early pregnancy with psychiatric co-management; never abruptly discontinue in the third trimester unless adverse fetal indication.
— PDD carries elevated lifetime suicide attempt rate (~15–20%); chronicity, hopelessness, and comorbid substance use are key drivers.
— Double depression episodes are particularly dangerous — escalation in severity often precedes attempts.
— Always assess and document SI, plan, intent, access to means (especially firearms — counsel on safe storage or temporary removal).
— Occupational impairment: underemployment, presenteeism, lost productivity. PDD has greater cumulative disability than episodic MDD due to duration.
— Relationship dysfunction: divorce, social isolation, parenting difficulties.
— Educational underachievement when onset is adolescent.
— Cardiovascular disease — depression is an independent risk factor for incident CAD and post-MI mortality; treat aggressively in cardiac patients (sertraline is preferred post-ACS).
— Diabetes — depression worsens glycemic control and adherence; HbA1c often rises.
— Obesity and metabolic syndrome — both disease-driven and medication-driven (mirtazapine, paroxetine).
— Chronic pain syndromes — fibromyalgia, migraine, low back pain.
— Dementia — chronic depression nearly doubles dementia risk in older adults.
— Alcohol, cannabis, opioids, sedatives — high comorbidity; concurrent treatment is essential, as untreated SUD undermines depression treatment.
— Serotonin syndrome with combinations (SSRI + tramadol, linezolid, triptans, MAOIs).
— SIADH/hyponatremia, GI bleeding, sexual dysfunction, weight gain, QT prolongation.
— Antidepressant discontinuation syndrome — taper over ≥4 weeks.
— Bipolar switch — antidepressant-induced mania reveals underlying bipolar disorder.
Board pearl: Post-MI depression doubles 6-month cardiac mortality — sertraline is the SSRI of choice (SADHART trial); avoid TCAs in cardiac patients due to conduction delay and orthostasis.
— Failure of two adequate antidepressant trials.
— Diagnostic uncertainty (bipolar suspected, psychotic features, personality pathology).
— Comorbid substance use disorder needing dual diagnosis program.
— Pregnancy/postpartum complexity.
— Need for augmentation with second-generation antipsychotic, lithium, or T3.
— Consideration of ECT, TMS, esketamine.
— Active SI with plan or intent.
— Recent suicide attempt.
— Command hallucinations.
— Severe functional decompensation, inability to perform ADLs.
— Acute psychosis or mania emerging on antidepressant.
— Imminent danger to self/others.
— Inability to maintain safety in current environment.
— Severe psychomotor retardation, catatonia, refusal to eat/drink.
— Need for ECT.
— Pregnant patient with severe depression requiring close monitoring.
— Involuntary commitment when patient declines voluntary admission and meets state criteria (typically danger to self/others or grave disability).
— Location: psychiatric unit (medical floor if comorbid acute medical issue).
— Safety: suicide precautions, 1:1 sitter if active SI, remove ligature/sharps, search belongings.
— Vitals q shift; weight on admission.
— Labs: CBC, CMP, TSH, B12, folate, urine drug screen, β-hCG, urinalysis, lipid panel, HbA1c, RPR.
— ECG before citalopram/TCA/antipsychotic.
— Initiate or optimize antidepressant; consider antipsychotic augmentation; psychiatry, social work, case management consults.
— C-SSRS at admission, daily, and discharge.
— Discharge planning from day 1: outpatient follow-up within 7 days, medication reconciliation, family involvement, lethal-means counseling, crisis plan with 988 number.
CCS pearl: Always order suicide precautions and 1:1 observation BEFORE labs when admitting a suicidal patient — patient safety orders are time-sensitive and graded heavily on the CCS.
— Discrete episodes of ≥2 weeks with full interepisode recovery. PDD lacks symptom-free intervals >2 months.
— Severity often greater; anhedonia and psychomotor changes prominent.
— Many patients have both ("double depression").
— Look for past manic (≥1 week, marked impairment, possible psychosis) or hypomanic (≥4 days, observable but no severe impairment) episodes.
— Red flags: early onset, atypical features (hypersomnia, hyperphagia), postpartum onset, family history, antidepressant-induced activation, mixed features.
— Treatment differs fundamentally — mood stabilizers ± atypicals, not SSRI monotherapy.
— ≥2 years of fluctuating hypomanic and depressive symptoms that don't meet full criteria; alternates rather than sustained low.
— Pediatric, ages 6–18; chronic irritability + severe temper outbursts. Distinguishes pediatric chronic irritability from bipolar.
— ≥6 months of excessive worry with physical symptoms; mood may be low secondarily.
— High overlap with PDD; often coexist. Treat both — SSRIs/SNRIs cover both.
— Trauma history, intrusion, avoidance, negative cognitions, hyperarousal. Negative mood is a criterion but trauma history and intrusive symptoms distinguish.
— Symptoms within 3 months of identifiable stressor, resolve within 6 months of stressor end. Duration excludes PDD by definition.
— Cyclic, luteal-phase symptoms; track with daily ratings ×2 cycles.
Key distinction: A patient with 3 years of low mood AND a 5-day episode of decreased sleep, racing thoughts, increased goal-directed activity — that's bipolar II with chronic depressive features, NOT PDD. Start a mood stabilizer (lamotrigine, lithium, quetiapine), not an SSRI alone.
— Hypothyroidism — fatigue, weight gain, cold intolerance, constipation, bradycardia. TSH screening is mandatory.
— Subclinical hypothyroidism can produce mood symptoms; consider treatment if TSH >10 or symptomatic with positive TPO antibodies.
— Cushing's syndrome — depression, hypertension, central obesity, striae, hyperglycemia.
— Addison's disease — fatigue, hyperpigmentation, hyponatremia/hyperkalemia.
— Vitamin B12 / folate deficiency, vitamin D deficiency.
— Iron deficiency anemia.
— Parkinson disease — depression precedes motor symptoms in 30%.
— Multiple sclerosis, stroke (especially left frontal), traumatic brain injury, dementia (especially frontotemporal, vascular).
— Obstructive sleep apnea — fatigue, irritability, cognitive impairment; treat OSA before declaring depression treatment-resistant.
— HIV, neurosyphilis, chronic hepatitis C, Lyme disease, SLE, vasculitis.
— Pancreatic cancer classically presents with depression preceding diagnosis.
— Alcohol — chronic use induces depression that may resolve with 4 weeks of abstinence.
— Cannabis, opioids, sedatives, stimulant withdrawal.
— Medications: β-blockers (less than historically believed), interferon-α, glucocorticoids, isotretinoin, hormonal contraceptives, varenicline (historical concern), levetiracetam, opioids.
— Borderline, avoidant, dependent — chronic dysphoria may be misdiagnosed as PDD; look for pervasive interpersonal patterns starting in adolescence.
Board pearl: A 55-year-old with new depression, weight loss, vague abdominal discomfort, and migratory thrombophlebitis — consider pancreatic cancer; obtain CT abdomen with contrast. New-onset depression in middle/late life always warrants medical workup.
— First MDD episode: 6–12 months continuation after remission.
— PDD or recurrent MDD (≥3 episodes): maintenance therapy ≥2 years, often indefinite at the dose that achieved remission.
— Never reduce dose during maintenance — full-dose continuation halves recurrence risk.
— Continue measurement-based care with PHQ-9 every 3 months in stable remission.
— Maintain psychotherapy gains with booster sessions every 1–3 months or mindfulness-based cognitive therapy (MBCT) — particularly effective for recurrent depression.
— Recognize early warning signs: sleep disruption, social withdrawal, irritability, anhedonia returning.
— Only consider after ≥2 years of full remission, in low-risk patient, during a stable life period (not during pregnancy, postpartum, job loss).
— Taper over 4 weeks minimum, longer for paroxetine, venlafaxine; consider switching to fluoxetine for taper (long half-life self-tapers).
— Inform patient that ~50% relapse within 2 years off medication; have plan to restart promptly.
— Aerobic exercise ≥150 min/week — comparable to SSRI in mild-moderate depression.
— Sleep regularity — fixed wake time, sleep ≥7 hours, treat OSA.
— Mediterranean-style diet — emerging evidence (SMILES trial).
— Alcohol moderation/abstinence; cannabis cessation.
— Social connection — group therapy, peer support, faith/community engagement.
— Light exposure — bright light therapy 10,000 lux × 30 min AM, especially seasonal pattern.
— Coordinate with PCP for hypothyroidism, diabetes, CAD; depression worsens all of these.
— Annual metabolic monitoring on atypical antipsychotic augmentation: weight, BP, fasting glucose, lipids.
Step 3 management: Patient with 4-year history of PDD now in 18 months of remission asks to stop sertraline — counsel that maintenance is recommended for ≥2 years post-remission, especially in chronic depression, and discuss the high recurrence rate before any taper.
— 1–2 weeks after starting any antidepressant — assess tolerability, suicidality (FDA mandate <25 yo), adherence.
— 2–4 week intervals through titration until remission.
— Measure PHQ-9 at every visit; aim for <5.
— Monthly visits during dose adjustments; every 3 months once stable.
— Annual labs: CMP (sodium), lipid panel, HbA1c, weight, BP.
— ECG at baseline and after dose changes for QT-prolonging agents.
— Lithium: level every 3–6 months (target 0.6–0.8); TSH and creatinine every 6–12 months; watch for tremor, polyuria, thyroid dysfunction.
— Atypical antipsychotics (aripiprazole, quetiapine): weight, fasting glucose, lipids, BP at baseline, 3 months, then annually; AIMS exam every 6 months for tardive dyskinesia.
— T3: TSH, free T4 every 3 months.
— Adherence — missing doses is the #1 cause of "treatment failure."
— Sexual side effects — proactively ask; options include dose reduction, switch to bupropion/mirtazapine, add bupropion, drug holidays (not for paroxetine/venlafaxine), sildenafil.
— Sleep hygiene, alcohol/substance use, exercise reinforcement.
— Lethal-means counseling at every visit when SI history present.
— Confirm engagement; track session attendance.
— Encourage homework completion in CBT/CBASP.
— Reassess therapy modality if no improvement in 8–12 sessions.
— Warm handoffs from inpatient → outpatient within 7 days post-discharge (a quality measure).
— Medication reconciliation at every transition; confirm pharmacy fill.
— Provide crisis number (988 Suicide & Crisis Lifeline) at every encounter.
CCS pearl: On the CCS, after starting an SSRI, advance the simulated clock to 2 weeks and reassess PHQ-9, side effects, and suicidality — not 6 weeks. Early follow-up is a graded patient-safety step.
— Discuss benefits, side effects (sexual dysfunction, weight, GI, hyponatremia, sleep), FDA black-box suicidality warning for <25 yo, expected timeline (4–6 weeks), need for prolonged therapy, discontinuation syndrome.
— Document discussion in the chart; particularly important for pregnant/postpartum patients (shared decision-making about fetal risk vs. untreated illness risk).
— Severe depression with hopelessness can impair decisional capacity for refusal of life-saving treatment (e.g., refusing ECT or nutrition).
— Formal capacity assessment uses four prongs: understanding, appreciation, reasoning, expressing a choice.
— A patient may have capacity for one decision and lack it for another; reassess as mood improves.
— Protect; but duty to warn/protect (Tarasoff) applies if patient discloses a credible plan to harm an identifiable third party — notify intended victim and law enforcement per state law.
— Imminent suicide risk justifies involuntary hold and breach of confidentiality.
— Suspected child, elder, or dependent-adult abuse/neglect — clinicians are mandated reporters in all 50 states.
— Intimate partner violence reporting varies by state; safety planning and resources always offered.
— Criteria typically: imminent danger to self/others or grave disability secondary to mental illness.
— Time-limited (usually 72 hours); requires judicial review for extension.
— Use least restrictive setting principle; voluntary admission preferred when feasible.
— Post-discharge suicide risk peaks in the first 30 days — schedule outpatient follow-up within 7 days, supply only limited quantities of potentially lethal medications, counsel on safe firearm storage/removal, involve family.
— Adolescents: parental consent generally required, but most states allow mature minor access to confidential mental health care; know your state.
— Pregnant women: fetal interest does not override maternal autonomy.
Step 3 management: A depressed patient hands you a list of medications and says "I might need these someday" — this is an oblique suicide disclosure. Conduct full risk assessment, contact family for means restriction, document, and arrange same-day psychiatric evaluation — do not simply continue the visit.
Board pearl: "Chronic 2+ years of depressive symptoms in an outpatient who functions but never feels well" → answer is PDD; start sertraline + refer to CBT.
Step 3 management: When two answer choices are plausible (medication vs. therapy), and the patient has chronic depression, the correct answer is almost always both — combination therapy is the highest-yield concept for PDD.
Persistent depressive disorder is a chronic, ≥2-year low-grade depression best treated with combined SSRI pharmacotherapy and structured psychotherapy (CBASP/CBT), maintained for ≥2 years after remission, while vigilantly screening for double depression, bipolarity, suicidality, and reversible medical mimics.
Board pearl: When you see "chronic, low-grade, functioning-but-joyless depression for years" on Step 3, the highest-yield single answer is start an SSRI and refer for evidence-based psychotherapy — combination therapy is the defining management principle of persistent depressive disorder.