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Approach to the Critical Patient
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
History
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
Physical Exam
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
Differential Diagnosis
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
Laboratory Tests
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
Diagnostic Tests
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
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
Disposition
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
Treatment
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
Special Populations
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
Background
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
Patient Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.