Patient handout

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

PRODUCTION

1. Your condition

This handout is for major depressive disorder (mdd) — chronic stepwise + acute crisis (apa 2023; va/dod 2022). Your care team identified this based on: depressed mood and/or anhedonia ≥2 weeks (dsm-5 2022 core symptoms).

Other reasons your team may use this plan: sleep / appetite / energy / concentration / psychomotor changes ≥2 weeks (dsm-5 2022 criterion a); suicidal ideation, plan, intent, or recent self-harm behavior (c-ssrs; apa 2023); phq-9 ≥10 on routine screening (siu jama 2016 uspstf).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
sertraline	25–50 mg PO daily	PO	once daily	Cipriani 2018 — among most effective + tolerable; preferred in pregnancy + cardiac disease
escitalopram	5–10 mg PO daily	PO	once daily	Cipriani 2018 — most effective SSRI; favourable interactions; QTc concern at higher doses
fluoxetine	10–20 mg PO daily	PO	once daily (mornings)	Long half-life buffers missed doses; FDA-approved adolescent MDD
paroxetine	10–20 mg PO daily	PO	once daily	Effective but anticholinergic; high discontinuation syndrome; AVOID in pregnancy — cardiac teratogen (FDA Category D); avoid in tamoxifen co-Rx — CYP2D6 (FDA 2011; APA 2023)
citalopram	10–20 mg PO daily	PO	once daily	Effective; FDA 2012 QTc warning caps dose 20 mg in elderly

Plan: MDD stepwise pharmacotherapy ladder — Step 1 SSRI → Step 4 ECT/TMS/esketamine (APA 2023; STAR*D Rush AJP 2006; VA/DoD 2022)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Doing well — PHQ-9 <5, no SI, functioning at baseline (APA 2023)

If you have:

Mood + sleep + energy + interest at baseline (APA 2023)
No suicidal thoughts (C-SSRS; Posner 2011)
Engaging with usual activities and relationships (APA 2023)

Do this:

Take antidepressant as prescribed every day — do not stop suddenly (APA 2023; CANMAT 2016)
Continue therapy / coping practices — exercise, sleep schedule, social engagement (NICE 2022; Cuijpers World Psych 2020)
Keep follow-up appointments (APA 2023)
Keep crisis line numbers available even when feeling well (VA/DoD 2022)

YELLOW — Caution — PHQ-9 rising or 5–14, return of symptoms, passive SI without plan (APA 2023)

If you have:

Sleep / appetite / energy declining (DSM-5-TR 2022 criterion A)
Loss of interest, hopelessness, increased irritability (DSM-5-TR 2022)
Passing thoughts that life is not worth living without intent or plan (C-SSRS; Posner 2011)
Increased alcohol or substance use (VA/DoD 2022)
Withdrawal from supports (APA 2023)

Do this:

Use coping strategies from your safety plan — call a support person, use distraction or grounding, reduce alcohol, increase activity (Stanley-Brown 2012)
Contact your provider for an early appointment — within 1 week (APA 2023)
Review medication adherence with provider — consider dose increase or augmentation if at adequate dose ≥4 weeks (STAR*D Rush AJP 2006; APA 2023)
Avoid means of self-harm — lock or remove firearms; secure or limit medications to short supply (VA/DoD 2022)

Call your provider if:

Symptoms not improving after 2 weeks of self-care (APA 2023)
PHQ-9 rises by ≥5 points (APA 2023)
Any thoughts of suicide become more frequent (VA/DoD 2022)
Functioning at work / home declines (APA 2023)

RED — Medical alert — active SI with intent or plan, plan to use means, recent self-harm, psychosis (APA 2023; VA/DoD 2022)

If you have:

Specific thoughts of how to end your life (C-SSRS; Posner 2011)
Access to means — firearms, large-quantity meds (VA/DoD 2022)
Recent self-harm or attempt (APA 2023)
Hearing voices or feeling unsafe with reality (APA 2023)
Inability to keep yourself safe (APA 2023)

Do this:

Call 988 (US) / your local crisis line / emergency services NOW (VA/DoD 2022)
Go to the nearest emergency department; do not be alone (APA 2023)
Hand any means (firearms, pills) to a trusted person before going (VA/DoD 2022)
Tell someone you trust what is happening (Stanley-Brown 2012)
Do not use alcohol or non-prescribed substances (APA 2023)

Call your provider if:

Any red zone trigger — emergency department immediately, do not wait (APA 2023; VA/DoD 2022)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

PHQ-9 ≥20 (severe MDD per Kroenke 2001)
C-SSRS positive for active SI with intent, plan, or recent preparatory behaviour (Posner 2011)(life-threatening)
Hallucinations, delusions, or catatonia in MDD (DSM-5-TR 2022)
Tremor, hyperreflexia, clonus, hyperthermia, autonomic instability, AMS in patient on serotonergic agents (Hunter criteria; Boyer NEJM 2005)(life-threatening)
Severe MDD in pregnancy or postpartum, with or without psychosis (APA 2023)
Tremor coarse, ataxia, confusion, GI symptoms with lithium augmentation (APA 2023)
Manic or hypomanic episode emerged on SSRI / SNRI / bupropion in patient previously screened MDQ-negative — DSM-5-TR criteria for manic / hypomanic episode now met (DSM-5-TR 2022; APA 2023; CANMAT 2016)
Flu-like + dizziness + electric-shock / "brain-zaps" + irritability + insomnia + rebound depressive symptoms within 1–3 days of abrupt cessation OR rapid taper of SSRI / SNRI — most severe with short-half-life agents (paroxetine, venlafaxine); commonly misdiagnosed as MDD relapse (Horowitz Taylor Lancet Psych 2019)
Treatment-resistant depression = failure of ≥2 adequate trials of antidepressants from different classes at adequate dose × adequate duration (≥4–8 wk at therapeutic dose). Pseudo-resistance (subtherapeutic dose / inadequate duration / non-adherence / unrecognised bipolar / medical mimic — TSH, B12, anemia, sleep apnea) must be ruled out FIRST (APA 2023; STAR*D Trivedi AJP 2006).
Severe depression OR psychotic features (delusions / hallucinations / disorganisation / suicidal or infanticidal ideation) with onset within 1 year of delivery (DSM-5-TR 2022 peripartum-onset specifier). Postpartum psychosis is a psychiatric emergency with infanticide / suicide risk; postpartum depression with SI also requires urgent evaluation (APA 2023).

5. Follow-up

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)

6. Sources

Guideline: APA Practice Guideline 3rd ed. (Gelenberg 2010) + APA 2023 update + VA/DoD MDD CPG 2022 + NICE NG222 2022 (CG222 superseded) + CANMAT 2016 Kennedy + CANMAT 2024 (verify)