Major depressive episodeMANAGEMENT

PSYCHIATRIC PRESENTATIONS · 12 SECTIONS

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637 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Acute anxiety Acute psychosis Agitation:behavioral emergency Anorexia Nervosa (Medical Complications)Bipolar disorder Bipolar Disorder (Depressive Episode)Bipolar Disorder (Manic Episode)Bulimia Nervosa (Medical Complications)Catatonia Conversion disorder Factitious Disorder Failure to Cope (Social)Failure to Thrive Generalized Anxiety Disorder Homicidal Ideation Major Depressive Disorder Major depressive episode Malingering Neuroleptic malignant syndrome Panic Attack Post-Traumatic Stress Disorder (Acute)Schizophrenia Exacerbation Suicidal Ideation Suicidal ideation and attempt Suicide Attempt

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp74

Immediate safety and triage

›Immediate priorities

›Airway compromise risk

›Intoxication or sedative coingestion

›Severe psychomotor retardation with poor airway protection

›Breathing compromise risk

›Opioid coingestion concern

›Aspiration risk with depressed consciousness

›Circulation compromise risk

›Dehydration from poor intake

›Hypotension from overdose concern

›Behavioral safety

›Imminent self harm risk

›Homicidal ideation risk

›Elopement risk

›Active intent

›Severe agitation

›High risk triggers

›Suicidality

›Active intent

›Recent attempt

›Psychosis

›Command hallucinations

›Mood congruent delusions

›Catatonia

›Stupor

›Rigidity

›Severe functional failure

›Inability to maintain hydration

›Inability to maintain nutrition

›Severe agitation

›Inability to participate in evaluation

›Need for rapid behavioral control

›Immediate environment

›Lethal means separation

›Secure medications

›Secure weapons access

›Observation level

›Continuous observation for imminent risk

›Close observation for moderate risk

›Medical monitoring

›Vital signs frequency based on intoxication risk

›Cardiac monitoring for overdose concern

Time critical decisions

›Disposition drivers

›Inpatient psychiatric admission indications

›Active intent with plan

›Inability to ensure safety outpatient

›Medical admission indications

›Delirium

›Toxic ingestion requiring monitoring

›Urgent specialty consultation triggers

›Psychiatry for high risk or diagnostic uncertainty

›Toxicology for overdose concern

›Capacity and consent

›Decision making capacity elements

›Understanding

›Appreciation

›Involuntary hold criteria by jurisdiction

›Danger to self

›Grave disability

Immediate stabilization options

›Acute agitation strategy

›Nonpharmacologic measures

›Low stimulation setting

›Verbal de escalation

›Pharmacologic measures

›If severe agitation then rapid tranquilization protocol per local policy

›If psychosis then antipsychotic selection mindful of QT risk

›Catatonia strategy

›Lorazepam challenge

›If rapid improvement then catatonia likely

›If no response then urgent psychiatry for ECT consideration

›Severe insomnia strategy

›Short term sedating agent selection

›Avoid high toxicity agents in overdose risk

›Avoid benzodiazepines with substance use disorder risk

02History/hx120

Core syndrome and timeline

›Presenting pattern

›Depressed mood

›Most of day

›Nearly every day

›Loss of interest or pleasure

›Social withdrawal

›Reduced enjoyment

›Duration threshold

›At least 2 weeks

›Clear change from baseline

›Symptom cluster

›Neurovegetative

›Sleep change

›Appetite or weight change

›Cognitive

›Poor concentration

›Indecisiveness

›Psychomotor

›Agitation

›Retardation

›Emotional

›Guilt or worthlessness

›Hopelessness

›Energy

›Fatigue

›Low motivation

›Self harm content

›Passive death wish

›Active ideation

›Functional impact

›Work or school impairment

›Absences

›Performance decline

›Self care impairment

›Hygiene decline

›Missed medical care

Suicide and violence risk

›Self harm risk formulation

›Ideation

›Frequency

›Intrusiveness

›Intent

›Desire to die

›Ambivalence

›Plan elements

›Preparatory behaviors

›Access to means

›Past behavior

›Prior attempts

›Prior nonsuicidal self injury

›Protective factors

›Reasons for living

›Social supports

›Homicidal or violence risk

›Ideation

›Targets

›Access to weapons

›Impulsivity

›Substance intoxication

›Recent aggression

Psychiatric history and differential drivers

›Prior mood episodes

›Prior depressive episodes

›Age at onset

›Number of episodes

›Bipolar spectrum screen

›Past mania or hypomania

›Antidepressant induced mood elevation

›Psychotic symptoms

›Hallucinations

›Mood congruent content

›Command content

›Delusions

›Guilt themes

›Nihilism themes

›Anxiety and trauma

›Panic symptoms

›Episodic surges

›Avoidance

›PTSD symptoms

›Reexperiencing

›Hypervigilance

›Substance use

›Alcohol

›Daily intake pattern

›Withdrawal history

›Cannabis

›Frequency

›High potency products

›Stimulants

›Cocaine

›Methamphetamine

›Opioids

›Use pattern

›Overdose history

Medical and medication contributors

›Medical comorbidities

›Endocrine

›Thyroid disease

›Diabetes

›Neurologic

›Stroke history

›Seizure disorder

›Sleep disorders

›Obstructive sleep apnea risk

›Circadian disruption

›Medication induced mood symptoms

›Corticosteroids exposure

›Recent start or dose increase

›Chronic use

›Interferon exposure

›Current therapy

›Recent therapy

›Isotretinoin exposure

›Current use

›Recent cessation

›Reproductive and peripartum context

›Pregnancy status

›Last menstrual period

›Contraception use

›Postpartum interval

›Delivery date

›Breastfeeding

03Physical Exam/exam56

General and mental status

›General findings

›Appearance

›Hygiene

›Eye contact

›Vital signs

›Fever

›Tachycardia

›Hydration and nutrition

›Dry mucous membranes

›Weight loss signs

›Mental status domains

›Affect

›Constricted

›Tearful

›Speech

›Latency

›Monotone

›Thought process

›Linear

›Ruminative

›Thought content

›Hopelessness

›Guilt

›Perception

›Hallucinations

›Derealization

›Cognition

›Attention

›Orientation

›Insight and judgment

›Recognition of illness

›Safety judgment

Focused medical exam

›Neurologic exam

›Focal deficits

›Weakness

›Aphasia

›Extrapyramidal signs

›Rigidity

›Tremor

›Endocrine and systemic clues

›Thyroid signs

›Bradycardia

›Goiter

›Cushingoid signs

›Proximal weakness

›Purple striae

PITFALLS

›Pitfalls

›Missed bipolar disorder

›History of decreased need for sleep

›Episodic increased goal directed activity

›Missed delirium

›Fluctuating attention

›Acute onset confusion

›Missed intoxication

›Constricted pupils

›Nystagmus

04Differential Diagnosis/ddx58

Primary psychiatric conditions

›Psychiatric differentials

›Major depressive episode

›ICD 10 F32.0 mild

›ICD 10 F32.1 moderate

›Major depressive episode severe

›ICD 10 F32.2 severe without psychotic symptoms

›ICD 10 F32.3 severe with psychotic symptoms

›Recurrent depressive disorder

›ICD 10 F33.0 recurrent mild

›ICD 10 F33.2 recurrent severe without psychotic symptoms

›Persistent depressive disorder

›ICD 10 F34.1 dysthymia

›Chronic course over 2 years

›Bipolar disorder depressive episode

›ICD 10 F31 series

›Mixed features possibility

›Adjustment disorder with depressed mood

›ICD 10 F43.21

›Clear stressor linkage

Medical and neurologic mimics

›Medical mimics

›Hypothyroidism

›Fatigue and weight gain

›Cold intolerance

›Hyperthyroidism

›Anxiety and insomnia

›Weight loss

›Anemia

›Fatigue

›Dyspnea on exertion

›Vitamin B12 deficiency

›Cognitive change

›Neuropathy

›Sleep apnea

›Daytime somnolence

›Snoring history

›Medication induced mood symptoms

›Corticosteroid exposure

›Interferon exposure

›Neurologic mimics

›Stroke or TIA

›Acute focal deficits

›Abrupt onset apathy

›Brain tumor

›New headache pattern

›Progressive focal deficits

›Dementia or mild cognitive impairment

›Memory predominant concerns

›Functional decline independent of mood

Substance related conditions

›Substance related differentials

›Alcohol induced depressive disorder

›Symptoms temporally linked to use

›Improvement with abstinence

›Stimulant withdrawal

›Hypersomnia

›Anhedonia

›Cannabis associated amotivation

›Chronic daily use

›Reduced initiative

05Laboratory Tests/lt30

Baseline medical evaluation

›Baseline screening

›Complete blood count for anemia infection concern

›Hemoglobin low as fatigue contributor

›Leukocytosis as inflammatory clue

›Electrolytes and renal function for dehydration and medication safety

›Sodium for hyponatremia risk

›Creatinine for lithium or dose planning

›Liver enzymes for hepatic disease and medication choice

›ALT AST baseline

›Albumin as chronic disease marker

Endocrine and nutritional tests

›Targeted contributors

›Thyroid stimulating hormone for thyroid disease suspicion

›Abnormal TSH then free T4 reflex

›Thyroid disease as reversible contributor

›Vitamin B12 for cognitive symptoms neuropathy risk or vegan diet

›Low level then methylmalonic acid if needed

›Replacement planning

›Folate for malnutrition risk

›Low folate as fatigue contributor

›Replacement planning

Pregnancy and toxicology

›Safety related tests

›Urine or serum pregnancy test for reproductive potential

›Medication selection implications

›Peripartum depression pathway

›Urine drug screen for altered mental status or diagnostic uncertainty

›Interpretation limits

›False positives and negatives

›Blood alcohol level for intoxication concern

›Capacity assessment implications

›Withdrawal risk planning

06Diagnostic Tests/dt44

Scoring Systems

›Symptom severity scales

›PHQ 9

›Total score severity bands for treatment intensity

›Item 9 as self harm ideation screen

›HAM D

›Clinician rated severity

›Monitoring response over time

›MADRS

›Sensitivity to change

›Use in specialty settings

›Suicide risk frameworks

›Columbia Suicide Severity Rating Scale

›Ideation intensity anchors

›Behavior history anchors

›SAFE T framework

›Risk factors

›Protective factors

MRI

›MRI indications

›New focal neurologic findings

›Localizing deficits

›Seizure onset

›New cognitive decline with atypical mood symptoms

›Rapid progression

›Prominent executive dysfunction

›Concern for demyelinating or inflammatory disease

›Optic neuritis history

›Multifocal deficits

›CT indications

›Acute neurologic deficit concern

›Stroke pathway activation

›Intracranial hemorrhage exclusion

›New severe headache with red flags

›Thunderclap onset

›Papilledema concern

›Trauma history with altered mental status

›Fall risk

›Anticoagulant use

Ultrasound (or US)

›Ultrasound uses

›Early pregnancy confirmation adjunct

›Positive pregnancy test with pain or bleeding

›Medication risk counseling context

›Point of care cardiac ultrasound for suspected overdose complications

›Hypotension evaluation

›Pericardial effusion screen

07Disposition/dispo34

Level of care decisions

›Inpatient psychiatric admission

›High suicide risk

›Active intent

›Recent attempt

›Psychotic depression

›Hallucinations with unsafe behavior

›Delusional guilt with refusal of care

›Catatonia

›Immobility

›Poor oral intake

›Medical admission

›Toxic ingestion or overdose concern

›Abnormal vital signs

›ECG abnormalities

›Delirium or unstable medical condition

›Fluctuating attention

›Infection concern

Outpatient pathway

›Outpatient criteria

›Low acute suicide risk

›No intent

›No preparatory behavior

›Reliable supports

›Supervision available

›Ability to restrict means

›Follow up arranged

›Mental health appointment within 1 week when possible

›Primary care appointment within 2 to 4 weeks

›Safety planning requirements

›Written safety plan

›Coping strategies

›Support contacts

›Means safety steps

›Medication lock and limited quantities

›Firearm removal from home when present

08Treatment/t132

Nonpharmacologic first line elements

›Core interventions

›Psychoeducation

›Illness course

›Treatment expectations

›Sleep and circadian stabilization

›Regular wake time

›Light exposure morning

›Behavioral activation

›Scheduled pleasurable activities

›Gradual activity increases

›Psychotherapy referral

›CBT

›IPT

Antidepressant monotherapy options

›SSRI options

›Sertraline dosing

›Initiate 25 to 50 mg daily

›Titrate 25 to 50 mg every 1 to 2 weeks

›Typical range 50 to 200 mg daily

›Common adverse effects

›GI upset

›Sexual dysfunction

›Escitalopram dosing

›Initiate 5 to 10 mg daily

›Titrate 5 to 10 mg every 1 to 2 weeks

›Typical range 10 to 20 mg daily

›QT risk considerations

›Higher dose caution

›Electrolyte correction if prolonged QT

›Fluoxetine dosing

›Initiate 10 to 20 mg daily

›Titrate 10 to 20 mg every 2 to 4 weeks

›Typical range 20 to 60 mg daily

›Activation risk

›Early agitation

›Insomnia

›SNRI options

›Venlafaxine XR dosing

›Initiate 37.5 to 75 mg daily

›Titrate 37.5 to 75 mg every 1 to 2 weeks

›Typical range 75 to 225 mg daily

›Blood pressure monitoring

›Dose related hypertension risk

›Baseline and follow up checks

›Duloxetine dosing

›Initiate 30 mg daily

›Titrate to 60 mg daily after 1 to 2 weeks

›Typical range 60 to 120 mg daily

›Pain comorbidity utility

›Neuropathic pain

›Fibromyalgia

›Other antidepressants

›Bupropion XL dosing

›Initiate 150 mg daily

›Titrate to 300 mg daily after 1 to 2 weeks

›Maximum 450 mg daily selected patients

›Contraindications

›Seizure disorder

›Eating disorder history

›Mirtazapine dosing

›Initiate 15 mg nightly

›Titrate 15 mg every 1 to 2 weeks

›Typical range 15 to 45 mg nightly

›Appetite and sleep effects

›Increased appetite

›Sedation

Augmentation and combination strategies

›If partial response at 4 to 8 weeks then strategy selection

›Dose optimization

›Adherence assessment

›Side effect limiting factors

›Switch strategy

›Within class switch for tolerability

›Cross class switch for nonresponse

›Augmentation strategy

›Aripiprazole augmentation

›Initiate 2 to 5 mg daily

›Titrate 2 to 5 mg every 1 to 2 weeks

›Typical range 2 to 15 mg daily

›Monitoring

›Akathisia

›Metabolic parameters

›Quetiapine XR augmentation

›Initiate 50 mg nightly

›Titrate to 150 mg nightly

›Typical range 150 to 300 mg nightly

›Monitoring

›Sedation

›Metabolic parameters

›Lithium augmentation

›Initiate 300 mg once or twice daily

›Titrate based on serum level

›Typical target 0.6 to 0.8 mmol per L for augmentation

›Monitoring

›Creatinine and electrolytes

›TSH

›Triiodothyronine augmentation

›Initiate 25 mcg daily

›Titrate to 50 mcg daily

›Limitations in cardiac disease

›Monitoring

›Heart rate

›Thyroid labs

Severe depression and rapid acting therapies

›Severe with psychotic features

›Antidepressant plus antipsychotic combination

›SSRI or SNRI selection based on comorbidity

›Antipsychotic selection mindful of metabolic risk

›ECT referral

›Rapid response need

›Refractory symptoms

›Treatment resistant depression

›Esketamine or ketamine pathway where available

›In clinic monitored administration

›Blood pressure monitoring during session

›TMS referral

›Noninvasive neuromodulation option

›Outpatient course

Safety and monitoring

›Early treatment risks

›Activation and anxiety

›Start low go slow strategy

›Close follow up first 1 to 2 weeks

›Bipolar switch risk

›Family history of bipolar disorder

›Past hypomanic symptoms

›Serotonin syndrome risk

›Multiple serotonergic agents

›Drug interaction review

›Follow up cadence

›High risk patients follow up within 72 hours

›Phone check in

›In person visit

›Standard follow up within 1 to 2 weeks after starting medication

›Side effect review

›Adherence review

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Risk benefit framing

›Untreated depression maternal and fetal risk

›Medication exposure risk discussion

›Medication selection

›Sertraline commonly used option

›Avoid paroxetine when possible due to congenital risk concern

›Postpartum depression screening

›EPDS use

›Psychosis red flags postpartum

Geriatric

›Geriatric considerations

›Lower starting doses

›SSRI start at half adult dose when frail

›Slower titration

›Hyponatremia risk

›Baseline sodium

›Recheck within 2 to 4 weeks after SSRI start

›Falls risk

›Sedating agents caution

›Orthostatic vitals

Pediatrics

›Pediatric considerations

›Diagnostic nuance

›Irritability as mood symptom

›School avoidance as functional marker

›Medication selection

›Fluoxetine evidence base in adolescents

›Escitalopram evidence base in adolescents

›Monitoring intensity

›Close follow up for suicidality after initiation

›Family engagement in safety planning

10Background/b30

Epidemiology

›Epidemiology

›Prevalence

›Common lifetime condition

›Higher risk in women

›Age distribution

›Peaks in young adulthood

›Recurrence risk over lifespan

›Comorbidity

›Anxiety disorders common

›Substance use disorders common

Pathophysiology

›Pathophysiology concepts

›Multifactorial etiology

›Genetic vulnerability

›Environmental stressors

›Neurobiology

›Monoamine signaling disruption

›HPA axis dysregulation

›Network dysfunction

›Reward circuitry hypofunction

›Cognitive control network inefficiency

Therapeutic Considerations

›Treatment principles

›Response time course

›Early partial improvement by 2 weeks possible

›Full response often 6 to 12 weeks

›Continuation phase

›Continue effective dose at least 6 to 12 months after remission

›Longer duration for recurrent episodes

›Discontinuation planning

›Gradual taper

›Discontinuation syndrome education

11Patient Discharge Instructions/pdi18

copy discharge instructions

›Discharge counseling

›Diagnosis explanation

›Depression is treatable

›Symptoms can improve with therapy and or medication

›Medication guidance

›Take as prescribed

›Do not stop suddenly without clinician guidance

›Safety plan

›Remove or secure medications and weapons at home

›Identify support person for check ins

›Follow up plan

›Mental health follow up scheduled

›Primary care follow up scheduled

›Return to ED now

›New or worsening thoughts of self harm

›Feeling unable to stay safe

›New hallucinations or paranoia

›Not eating or drinking for 24 hours

12References/r11

Evidence and guideline sources

›Reference set

›Major depressive disorder clinical practice guidelines

›APA practice guideline for treatment of depression

›NICE depression guideline

›Canadian guideline sources

›CANMAT depression guidelines

›Provincial mental health pathways

›Suicide risk and safety planning resources

›Columbia Suicide Severity Rating Scale materials

›Safety planning intervention framework

›Project system file

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.