🌧 Symptom-Based Approach: Depression

“Why does this patient feel so low?” — Let’s not just label it. Let’s understand it.

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🚪 Doorway Information

• Age: 32
• Gender: Female
• Chief Complaint: “I feel tired and nothing is enjoyable anymore.”
• Vitals: BP 118/70, HR 72, RR 14, Temp 36.8°C, SpO₂ 98%

🧩 What do you consider first?

Depression? Maybe.
But before jumping to conclusions, take a breath.
Not all sadness is depression — and not all depression is psychological.

📋 Clinical Vignette

Here’s more:

• She has trouble falling asleep and wakes up early.
• Lost 3 kg over the past month.
• No suicidal ideation, but she says, “I wouldn’t mind if I disappeared.”
• No psychiatric history.
• Work and social life have suffered.
• Physical exam and labs (CBC, TSH, CMP, CRP) are normal.

🔎 Think Broad, Then Narrow: VITAMIN CDE

• Vascular: Stroke (frontal lobe, basal ganglia)
• Infectious: HIV, neurosyphilis, hepatitis
• Trauma: Concussion, emotional trauma, abuse
• Autoimmune: SLE, MS, autoimmune thyroiditis
• Metabolic: Electrolyte imbalance, B12/folate deficiency
• Iatrogenic/Drugs: Corticosteroids, isotretinoin, alcohol withdrawal
• Neoplastic: Brain tumor, paraneoplastic syndrome
• Congenital/Genetic: Wilson’s, Huntington’s (rare)
• Degenerative: Early-onset dementia, FTD
• Endocrine: Hypothyroidism, Cushing’s, Addison’s, diabetes

🧪 PHQ-9: Screening & Monitoring

What is PHQ-9?

• 9-item self-report tool based on DSM-5
• Used for screening, diagnosis, and tracking
• PHQ-2 (Q1+Q2) as quick screening

Scoring:

Score	Severity
0–4	Minimal
5–9	Mild
10–14	Moderate
15–19	Moderately severe
20–27	Severe

⚠️ Question 9 asks about suicidality. Always follow up if positive.

📝 Download the official PHQ-9 form (PDF):
PHQ-9_English.pdf

💊 First-Line Management

• Psychoeducation: It’s a medical condition. It’s treatable.
• Lifestyle: Daily routine, sleep hygiene, exercise
• Therapy: CBT is most evidence-based
• Medication: Start SSRI (e.g. sertraline, escitalopram)
• Start low, reassess at 4–6 weeks
• Continue for 6–12 months after remission

🚩 Red Flags

• Suicidal ideation or previous attempt
• Psychotic symptoms (e.g. delusions)
• Severe functional impairment
• Elderly patient with new symptoms
• No improvement with treatment

🔬 When to Refer

• No response to ≥2 antidepressants
• Suspected bipolar disorder
• Suicidal or psychotic features
• Need for psychotherapy or diagnostic support

🪞 Clinical Reflection

This is classic masked depression: fatigue, insomnia, weight loss, withdrawal.
She never says “I’m depressed” — but “I wouldn’t mind disappearing” speaks volumes.
Always listen for these indirect signs.

💡 Clinical Pearls

• Depression ≠ just mood. Think sleep, energy, motivation.
• PHQ-9 is useful, but not diagnostic alone.
• Rule out organic causes before labeling it “psychiatric.”
• Ask: “When did you last enjoy something?”

Want to practice clinical English and apply what you’ve learned?
👉 Try our realistic case-based interview:

🎭 Mock Patient note: Depression – Standard

Prefer to read this in Japanese?
🇯🇵 日本語版はこちら

⬅ Back to Symptom-Based Approach Home

📚 References

1. Kroenke K, Spitzer RL, Williams JB. PHQ-9 validity. J Gen Intern Med. 2001.
2. APA PHQ-9 Form
3. NICE CG90: Depression in adults. 2009.
4. Stern TA, et al. MGH Psychiatry. 2nd ed.