PANCE Blueprint Psychiatry (6%)

Depressive disorders (Pearls)

Depressive disorders
Major depressive disorder A mood disorder in which a person experiences, in the absence of drugs or a medical condition, two or more weeks of significantly depressed moods, feelings of worthlessness, and diminished interest or pleasure in most activities.
Persistent depressive disorder (dysthymia) Mood disorder involving persistently depressed mood, with low self-esteem, withdrawal, pessimism, or despair, present for at least 2 years, with no absence of symptoms for more than 2 months.
Premenstrual dysphoric disorder A disorder marked by repeated episodes of significant depression and related symptoms during the week before menstruation
Suicidal/homicidal behaviors Mood disturbances, somatic complaints, feeling hopelessness, worthlessness, helplessness
Major depressive disorder
a 33-year-old woman complaining of fatigue and decreased interest in “the things that used to make me happy.”  She is sleeping less and eating less, and she says that she is forcing herself to eat “because I know I have to eat something.” She finds herself spending less time with her kids and husband as she retreats to her room. She feels guilty that she lacks the energy and enthusiasm she used to have.

5 or more SIEGECAPS for≥ 2 weeks nearly every day and at least one of the symptoms is depressed mood or anhedonia


  • Sadness
  • Interest/anhedonia
  • Guilt
  • Energy
  • Concentration
  • Appetite
  • Psychomotor activity
  • Suicidal


SSRIs are the first line treatment

  • Continue to increase dosage q3–4wk until symptoms in remission.
  • Full medication effect is complete in 4–6 weeks. Augmentation with 2nd medication may be necessary.
  • See within 2–4 weeks of starting medication and q2wk until improvement, then monthly to monitor medication changes
Persistent depressive disorder (dysthymia)
Patient will present as → a 30-year-old married male who feels down most of the time for the past three years. He experiences frequent, intrusive thoughts that he is not good enough, despite personal and professional successes. He tries to overcompensate for his thoughts by taking on more than he can handle, which leads to failure and furthers his feelings of inadequacy. His wife suggests that he seek help after finding him crying.

A patient with chronic depression for two years or more

Chronic depressions - depressive symptoms for > 2 years

  • The individual has never been without the depressive symptoms in for more than 2 months at a time.
  • There has never been a manic episode or a hypomanic episode


  • SSRIs and other antidepressants
  • Psychotherapy
  • Physical exercise
Premenstrual dysphoric disorder
Patient will present as → a 26-year-old patient is complaining of depression and anxiety just prior to her menses. The symptoms have been going on for more than 1 year, but are now starting to interfere with her relationships and her productivity at work. One week prior to menses each month she experiences a depressed mood, a feeling of being on edge, increased irritability, difficulty sleeping, a feeling of being overwhelmed, and is easily fatigued. She charted her symptoms daily in a log and returned to the office two cycles later. The log is consistent with the history. Her physical examination and general laboratory profile showed no abnormalities.

Repeated episodes of significant depression and related symptoms during the week before menstruation

In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses.

One (or more) of the following symptoms must be present:

  • Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).
  • Marked irritability or anger or increased interpersonal conflicts.
  • Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
  • Marked anxiety, tension, and/or feelings of being keyed up or on edge.

One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from above.

  • Decreased interest in usual activities (e.g., work, school, friends, hobbies).
  • Subjective difficulty in concentration.
  • Lethargy, easy fatigability, or marked lack of energy.
  • Marked change in appetite; overeating; or specific food cravings.
  • Hypersomnia or insomnia.
  • A sense of being overwhelmed or out of control.
  • Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain.


SSRIs are first-line treatment (fluoxetine, sertraline, paroxetine, escitalopram) and can be used continuously or instituted the week prior to menses.

  • Birth control, low-dose estrogen, and diuretics may also be beneficial.
  • SNRIs such as venlafaxine may also be effective in women with predominantly psychological symptoms.
  • Gonadotropin-releasing hormone (GnRH) -  SEs include accelerated bone loss and vasomotor symptoms
Suicidal/homicidal behaviors
Patient will present as → a 17-year-old female who attempts suicide by swallowing several tablets of acetaminophen.

Suicide is the 8th leading cause of death in the United States and the 3rd leading cause of death in ages 15-24 years.

  • In all age groups, male deaths by suicide outnumber female deaths 4 to 1
  • Women attempt suicide 2 to 3 times more often than men; among girls aged 15 to 19 yr, there may be 100 attempts to every 1 attempt among boys of the same age.
  • On average, primary care physicians encounter ≥ 6 potentially suicidal people in their practice each year.
  • About 77% of people who die by suicide were seen by a physician within 1 yr before killing themselves, and about 32% had been under the care of a mental health care practitioner during the preceding year.

Assess level of intent, level of lethality, risk factors:

  • Male gender
  • Older
  • Major depression
  • Active substance abuse
  • Serious medical problems
  • Recent loss (e.g. of employment, relationship, death of family member)

Consider referral to emergency services

  • Crisis service, emergency department
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