Effective management of major depressive disorder requires accurate diagnosis, severity assessment, and a structured, stepped-care approach. In this concise clinical overview, Dr. Jessica Gurley outlines diagnostic criteria, use of validated screening tools, evidence-based psychotherapy and medication strategies, augmentation considerations, and referral thresholds. The discussion is designed to support primary care clinicians in delivering safe, effective, and guideline-aligned depression care.
Good morning everyone. My name is Jessica Gurley. I am a psychiatrist and the director of medical operations for behavioral health for SMG South Side. Today we're gonna be talking about depression and best practices in clinical management. A major depressive episode is when symptoms are clinically present for at least 2 weeks. We're gonna have to have uh a presence of either a depressed mood and or anhedonia, which is decreased motivation. With along with four of the following symptoms, changes in appetite, hypersomnia or insomnia, psychomotor activation or slowing, decreased energy, feelings of worthlessness or guilt, difficulties with thought process, concentration, decision making, and also can have some thoughts of suicide. When a major depressive episode is present, we do want to take a look at the severity of the symptoms because then we can assess whether it's a severe, moderate, or a mild case of depression. Mild symptoms would be distressing but manageable, whereas severe would be unmanageable and severely distressing where there's impacting of functioning. Regardless of the scale, we always want to assess for suicidality and within that, we always want to ask direct questions to assess for suicidality. The best screening tool that we have and we have readily accessible in Epic and with Centera is the PHQ9 screening tool. It's a very well validated screening tool that every 30 days is validated to get you um good data. Additionally, within the suicidality, we have access to the Columbia suicide screener, which is also in EPI and we can also access. A step care approach is one of the recommended approaches to dealing with depression. Not every patient's ready for therapy and not every patient's ready for psych uh psychopharmacology. When we looked at step care, um, all patients, we should be encouraging healthy diet, good sleep hygiene, and avoiding substances. If a patient's sub-syndromal or having mild symptoms, cognitive behavioral therapy is a good first line, and we try to avoid antidepressants as the first line in these mild cases, unless it's the patient's preference. Starting with an SSRI or a selective serotonin reuptake inhibitor is a good option. And we want to treat for at least 6 months following symptom remission. For moderate to severe cases, a combination of CBT or cognitive behavioral therapy and an antidepressant is a good option. We also want to encourage behavioral activation like taking walks, getting outside, and getting up and moving. Within the moderate to severe depressive episodes, we would recommend first line is pharmacology. A good option is sertraline. It's not only good for any person, but it's a really good option for patients who are breastfeeding or pregnant. Fluoxetine is one of our most weight neutral options within the SSRI category, and if you're looking outside of SSRIs, bupropion, which is an NDRI is going to be weight neutral and it's also not going to have sexual side effects. Rapid titration of these medications as tolerated is a really good way to make sure that the patient's gonna get the best effect, um, as soon as we can. But also just remember that these medications take about 4 to 6 weeks to kick in at an adequate therapeutic dose. So we really want to make sure that not only when we start the medication, that we want to get it up to whatever the therapeutic dose is. And whatever therapeutic dose is, is when we actually see a response. So if you're not seeing a response at a therapeutic dose, we could switch within the same class, but if you see a partial response, go ahead and increase the dose to a tolerated dose and add an augmenter if an increased dose is not tolerated. I just mentioned an augmenting agent, and these are agents that when your first trial has a partial response and doesn't have the upwards of the full response that you want it to have, we can add other medications to help boost the effects of that primary trial. A good option would be bupropion if you haven't used it as a first line. Starting at 150 mg and titrating it up to 300 as tolerated, but we can also really be looking for any problems with people with a seizure disorder or an eating disorder because that will cause you some more problems. We also can look at using antipsychotics as they're FDA approved for augmentation for major depressed depressive disorder. Aripiprazole starting at 2 mg, it's very well tolerated for the most part, but we do want to watch out for extra pyramidal symptoms like akathisia. Lorazodone is another antipsychotic that needs to be taken with food, but usually well tolerated. And for somebody with insomnia, quetiapine is a good option as well, because it's very sedating. Starting at 15 mg at nighttime. is a good, is great and it will help them sleep, but we do need to watch out for appetite and weight gain because that is a major side effect. These medications need to be continued for about 6 to 9 months following symptom remission, and then you can look to titrate them off. And again, if you failed two trials or if you failed multiple augmenting agents, that is a great time to refer to psychiatry. A new feature that behavioral health is optimizing over the last year is uh the use of e-consults. E-consults are a great way if you have specific clinical questions about treatment management, some side effect management, or any next augmenting options for the patient. Feel free to put an e-consult in, including symptoms, side effects, and we with psychiatry can help kind of guide the next treatment step with you. Also, if that's not working or the patient's failed a couple of trials of medications and you just feel like this patient's a little bit more complex, feel free to send a referral and we'd be happy to see the patient.
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