PANCE Blueprint Psychiatry (7%)

Depressive disorders (Pearls)

PANCE Blueprint Psychiatry (7%)

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 with seasonal pattern (SAD)	Recurrent major depressive episodes that begin and fully remit at characteristic times of year — most commonly fall/winter onset with spring remission

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. ≥ 2 weeks of depressed mood or anhedonia + SIGECAPS symptoms SIGECAPS: Sleep · Interest loss · Guilt · Energy · Concentration · Appetite · Psychomotor changes · Suicidality Screen with PHQ-9 and reassess with it; screen for prior mania/hypomania before starting an antidepressant DX: DSM-5 — ≥ 5 of 9 symptoms for ≥ 2 weeks nearly every day, with ≥ 1 being depressed mood or anhedonia, causing functional impairment Exclude bipolar disorder, substances, and medical causes (TSH, B12 when indicated) TX: SSRI first-line + psychotherapy (CBT) — combination beats either alone Allow 4–6 weeks at therapeutic dose before calling a medication a failure ECT for refractory, psychotic, or catatonic depression, or when rapid response is needed (pregnancy, refusal to eat/drink)
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. Chronic depression — depressive symptoms for > 2 years, never symptom-free > 2 months "Double depression" = a major depressive episode superimposed on dysthymia DX: DSM-5 — depressed mood most of the day, more days than not, for ≥ 2 years (≥ 1 year in children/adolescents, mood can be irritable) + ≥ 2 of: appetite change · sleep change · low energy · low self-esteem · poor concentration · hopelessness Never symptom-free > 2 months during the period TX: Psychotherapy + SSRI — combination beats either alone Reassess over time for conversion to (or co-occurrence of) major depressive episodes
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. Severe mood swings, irritability, and depressed mood in the week before menses that resolve within days of onset of menses Distinguished from PMS by severity and functional impairment, with a required core mood symptom DX: DSM-5 — ≥ 5 symptoms in the final week before menses with ≥ 1 core mood symptom (lability · irritability · depressed mood · anxiety), improving within days of menses onset and minimal postmenstrually Present in most cycles of the past year; confirm with prospective daily ratings across ≥ 2 cycles — retrospective recall is unreliable TX: SSRI first-line — continuous or luteal-phase-only dosing Drospirenone-containing OCP is an alternative; CBT and exercise as adjuncts
Suicidal/homicidal behaviors	Patient will present as → a 17-year-old female who attempts suicide by swallowing several tablets of acetaminophen. Ask directly — asking about suicide does NOT increase risk Prior attempt is the strongest predictor; risk rises with older age, male sex, living alone, firearm access, substance use, chronic illness, and recent loss Homicidal ideation with an identifiable victim → duty to warn/protect (Tarasoff) DX: Structured risk assessment — ideation → plan → intent → access to lethal means Screen with PHQ-9 item 9, then the Columbia (C-SSRS) for positive screens TX: Imminent risk: hospitalize (involuntarily if necessary) + remove lethal means + safety planning Treat the underlying disorder; lithium (mood disorders) and clozapine (schizophrenia) reduce suicide risk Closest follow-up in the weeks after discharge — the highest-risk period
Major depressive disorder with seasonal pattern (SAD)	Patient will present as → a 28-year-old woman seen in mid-November with depressed mood and low energy — the third consecutive winter this has happened. She is sleeping 11 hours a night, craving carbohydrates, and has gained 8 pounds, and her symptoms have fully resolved each spring. Screening for mania is negative. She begins morning bright light therapy, and within two weeks her mood, energy, and sleep normalize. MDD with seasonal pattern — "seasonal affective disorder" is not a standalone diagnosis but a specifier of recurrent MDD (or bipolar disorder); more common in women, young adults, and higher latitudes Fall/winter onset with full spring remission for ≥ 2 consecutive years — and no nonseasonal episodes in that period Atypical features dominate — hypersomnia, carbohydrate craving, and weight gain (the reverse of melancholic features) vs persistent depressive disorder — PDD is chronic low-grade depression that may worsen in winter; the seasonal specifier requires discrete episodes with full remission DX: DSM-5 seasonal pattern specifier Regular temporal relationship between episode onset and time of year, with full remission at a characteristic time (classically spring) Two seasonal episodes and zero nonseasonal episodes in the last 2 years; seasonal episodes substantially outnumber nonseasonal ones lifetime Exclude episodes better explained by seasonal psychosocial stressors (e.g., seasonal unemployment) TX: Morning bright light therapy first-line — 10,000 lux for 20–30 minutes within an hour of waking; response in 1–2 weeks SSRIs (fluoxetine, sertraline) equally effective; CBT for seasonal depression gives the most durable benefit across future winters Bupropion XL is FDA-approved for prevention — start in early fall before symptoms begin ⚠️ Rule out bipolar disorder first — light therapy and antidepressants can precipitate mania

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