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psych.depression.core.v1

Major Depressive Disorder (MDD) — chronic stepwise + acute crisis (APA 2023; VA/DoD 2022)

psychiatrychronicacuteadultoutpatientacutetransition
Start encounter →Print handoutPRODUCTION

MDD dossier — APA + VA/DoD + NICE + CANMAT current 2026 Step 1 SSRI: sertraline 25 → 200, escitalopram 5 → 20, fluoxetine 10 → 60, paroxetine 10 → 50, citalopram 10 → 40 (20 if elderly) Step 2 switch: venlafaxine XR 37.5 → 225, duloxetine 30 → 60–120, bupropion XL 150 → 300, mirtazapine 7.5 → 45 Step 3 augmentation: lithium target 0.6–0.8, T3 25–50 mcg, aripiprazole 2–15, quetiapine XR 150–300, brexpiprazole 0.5–3, olanzapine-fluoxetine combo, bupropion combination Step 4 neuromodulation / esketamine: ECT for severe / refractory / psychotic / suicidal / pregnancy; TMS daily 4–6 weeks; esketamine 56–84 mg intranasal twice weekly induction Action plan includes Stanley-Brown safety planning + means restriction + 988 lifeline + green/yellow/red warning signs Severity triggers: PHQ-9 ≥20, active SI with intent / plan / means, psychotic features / catatonia, hidden mania, serotonin syndrome, perinatal severe MDD, lithium toxicity Sibling differentiation against psych.bipolar-disorder.core.v1 (authored 2026-05-13) + psych.suicidality.ed.core.v1 (authored 2026-05-13; B.8 re-dispatch) PRODUCTION blockers: (1) RxCUIs not yet populated, (2) manifest stub blank, (3) registry import not added per instructions, (4) sibling references psych.bipolar.core.v1 which may not yet exist depth-pass-1 (2026-05-14): authored co-located depth design brief (_briefs/psych.depression.core.v1.depth.md — companion to preserved 2026-04-27 brief) + co-located research bundle (_research-bundles/psych.depression.core.v1.md); added 4 new severity-trigger rows (antidepressant_induced_mania severe → routes to psych.bipolar-disorder.core.v1; antidepressant_discontinuation_syndrome severe → Horowitz hyperbolic taper plan; treatment_resistant_depression severe → STAR*D ≥2 adequate trials failed gateway to Step-3 augmentation / Step-4 neuromodulation / esketamine; postpartum_mdd_or_psychosis_features severe → urgent reproductive psychiatry + brexanolone / zuranolone / ECT-safe consideration); refined outpatient setting_playbook non_drug_actions with explicit Horowitz hyperbolic taper line + lethal-means counseling line + MDQ-at-every-visit line + Stanley-Brown safety-plan line + SDoH screen line + relapse-prevention-plan line + exercise prescription dosing; appended 6 canonical PMIDs to evidence.pmids (Trivedi STAR*D AJP 2006 16390886; Kroenke PHQ-9 2001 11556941; Spitzer GAD-7 2006 16717171; Cipriani Lancet 2018 NMA alternative-index 29477251; Posner C-SSRS 2011 22193671; Gelenberg APA 2010 historical anchor 20667285); bumped last_reconciled 2026-04-27 → 2026-05-14. Audit baseline [OK] PRODUCTION preserved.

Entry points (6)

  • symptom
    Depressed mood and/or anhedonia ≥2 weeks (DSM-5 2022 core symptoms)
    depressed_mood_anhedonia
  • symptom
    Sleep / appetite / energy / concentration / psychomotor changes ≥2 weeks (DSM-5 2022 criterion A)
    somatic_depressive_symptoms
  • symptom
    Suicidal ideation, plan, intent, or recent self-harm behavior (C-SSRS; APA 2023)
    suicidal_ideation_or_behavior
  • lab_abnormality
    PHQ-9 ≥10 on routine screening (Siu JAMA 2016 USPSTF)
    positive_phq9_screen
  • problem_list
    Existing MDD with inadequate response, relapse, or breakthrough symptoms (STAR*D Rush AJP 2006)
    mdd_existing_uncontrolled
  • history
    Perinatal / postpartum / perimenopausal mood symptoms (APA 2023)
    postpartum_or_perimenopausal

Required inputs (17)

  • agerequired
    demographic • used at CONTEXT
    Drug selection; geriatric (lower starting doses); adolescent (FDA 2004 black-box reassessment; TADS March JAMA 2004)
  • pregnancy_statusrequired
    demographic • used at CONTEXT
    SSRI choice (sertraline preferred APA 2023); avoid paroxetine (FDA Category D); bupropion + mirtazapine considerations
  • phq9_scorerequired
    symptom • used at RISK_STRATIFICATION
    PHQ-9 stratifies severity → drug + therapy intensity; Q9 flags suicidality (Kroenke 2001; APA 2023)
  • suicidality_assessmentrequired
    symptom • used at RED_FLAGS
    C-SSRS — passive vs active vs intent vs plan drives disposition (Posner 2011; VA/DoD 2022)
  • prior_antidepressant_responserequired
    history • used at CONTEXT
    STAR*D (Rush AJP 2006) — prior response determines next step in failure ladder
  • manic_or_hypomanic_historyrequired
    history • used at CONTEXT
    Rule out bipolar — MDD treatment differs and antidepressant alone may precipitate switch (APA 2023; CANMAT 2016)
  • substance_userequired
    history • used at CONTEXT
    Concurrent SUD worsens prognosis; tailor regimen + counsel (VA/DoD 2022; Anton JAMA 2006 COMBINE)
  • psychosocial_stressors
    history • used at CONTEXT
    Acute stressors / abuse / housing affect plan and safety (APA 2023)
  • medical_comorbidityrequired
    history • used at CONTEXT
    CV, renal, hepatic, seizure, eating disorder affect drug choice (e.g., bupropion contraindicated in seizure / eating disorder; APA 2023; VA/DoD 2022)
  • current_medsrequired
    medication • used at CONTEXT
    MAOI washout; serotonergic load; CYP interactions; QTc; tamoxifen + paroxetine/fluoxetine (FDA 2011); SSRI + NSAID bleeding (APA 2023)
  • tshrequired
    lab • used at INITIAL_WORKUP
    Hypothyroidism mimics depression — baseline before initiating SSRI (APA 2023; VA/DoD 2022)
  • cbc
    lab • used at INITIAL_WORKUP
    Baseline before therapy; rule out anemia / occult illness (VA/DoD 2022)
  • bmp
    lab • used at INITIAL_WORKUP
    Baseline electrolytes; SIADH risk on SSRI; lithium readiness (APA 2023)
  • lft
    lab • used at INITIAL_WORKUP
    Hepatic-cleared antidepressants (VA/DoD 2022)
  • glucose_a1c
    lab • used at INITIAL_WORKUP
    Atypical antipsychotic augmentation requires metabolic baseline (APA/ADA 2004 consensus)
  • lipid
    lab • used at INITIAL_WORKUP
    Atypical antipsychotic baseline metabolic monitoring (APA/ADA 2004 consensus)
  • ecg
    imaging • used at INITIAL_WORKUP
    QTc baseline before TCAs / citalopram >20 mg (FDA 2012) / atypical antipsychotic augmentation

12-phase flow (12)

  1. 1FRAME
    Confirm DSM-5-TR 2022 MDD criteria (≥5 symptoms ≥2 weeks including depressed mood or anhedonia, functional impairment, not better explained by SUD / medical / bereavement / bipolar)
    advance: MDD criteria met and bipolarity ruled out (DSM-5-TR 2022; APA 2023)
  2. 2ENTRY
    Trigger from PHQ-9 ≥10 (Siu JAMA 2016 USPSTF), symptomatic presentation, postpartum risk, or relapse
    inputs: age, phq9_score
    advance: Entry criteria documented
  3. 3CONTEXT
    Prior antidepressant trials + response (STAR*D Rush AJP 2006), manic history, substance use, psychosocial stressors, medical comorbidities, current meds, pregnancy
    inputs: prior_antidepressant_response, manic_or_hypomanic_history, substance_use, medical_comorbidity, current_meds, pregnancy_status
    advance: Personalisation data captured
  4. 4RED_FLAGS
    Active suicidality with intent / plan / means (C-SSRS; VA/DoD 2022); psychosis; severe agitation; inability to care for self; pregnancy with severe MDD; postpartum psychosis
    inputs: suicidality_assessment
    actions: workup.suicide_risk
    advance: Safety plan in place OR involuntary admission initiated (APA 2023; VA/DoD 2022)
  5. 5INITIAL_WORKUP
    TSH, CBC, BMP, LFTs (baseline per APA 2023); A1c + lipids if atypical antipsychotic augmentation contemplated (APA/ADA 2004); ECG if QTc-prolonging drug planned (FDA 2012); pregnancy test
    inputs: tsh, cbc, bmp, lft
    advance: Baseline labs returned
  6. 6BRANCHING_WORKUP
    Sleep study if treatment-resistant + OSA suspected; B12 / folate / vitamin D if older / restricted diet; HIV / RPR / heavy metals if atypical presentation; structural neuroimaging if late-onset / focal findings (APA 2023)
    advance: Targeted workup obtained when triggered
  7. 7DIFFERENTIAL
    Adjustment disorder vs persistent depressive disorder vs MDD with mixed features vs bipolar depression vs PMDD vs hypothyroidism vs anemia vs medication-induced (interferon, β-blocker, isotretinoin, steroids) (DSM-5-TR 2022; APA 2023)
    advance: Working diagnosis assigned
  8. 8RISK_STRATIFICATION
    PHQ-9 severity (mild 5–9, moderate 10–14, mod-severe 15–19, severe ≥20; Kroenke 2001); Columbia C-SSRS (Posner 2011); functional impact; psychosocial supports
    inputs: phq9_score, suicidality_assessment
    advance: Severity tier + safety plan documented (APA 2023)
  9. 9TREATMENT
    Mild: psychotherapy ± SSRI (NICE 2022; Cuijpers World Psych 2020); Moderate-severe: SSRI first-line + therapy (APA 2023; Cipriani Lancet 2018); failure → switch class (STAR*D Rush AJP 2006) → augment (lithium / T3 / atypical) → ECT / TMS / esketamine; treat for ≥6–9 mo after remission, ≥1–2 yr if recurrent (CANMAT 2016 Kennedy)
    inputs: current_meds
    advance: Stepwise plan documented + therapeutic dose targeted (APA 2023)
  10. 10DISPOSITION
    Outpatient: most cases; ED → involuntary hold for active SI with intent / plan / means; partial hospitalisation / IOP for moderate-severe with intact function; inpatient psychiatry for high suicide risk, psychosis, catatonia, severe agitation, inability to care for self (APA 2023; VA/DoD 2022)
    advance: Level of care set (APA 2023)
  11. 11MONITORING
    PHQ-9 at 2, 4, 6, 8, 12 weeks (APA 2023); first 4 weeks of any antidepressant high suicide watch (FDA 2004 black-box); side-effect screen (sexual, GI, sleep, weight, hyponatremia in elderly); response = 50% PHQ-9 reduction; remission = PHQ-9 <5 (STAR*D Rush AJP 2006)
    advance: Response or remission OR step-up
  12. 12FOLLOWUP
    Continue treatment ≥6–9 months after remission for first episode; ≥1–2 years for recurrent; lifelong if ≥3 episodes (APA 2023; CANMAT 2016 Kennedy); relapse-prevention therapy (CBT / MBCT) reduces relapse 30–50% (Cuijpers World Psych 2020); lifestyle (exercise, sleep hygiene, alcohol reduction, social engagement)
    advance: Maintenance plan in place