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S: Subjective
Reason for visit: Medication follow-up for major depressive disorder.
Interval history: A 38-year-old woman started sertraline 10 weeks ago and has taken 100 mg daily for the past 6 weeks. She says her mood is "better but not back to normal." She is sleeping 6 hours a night, up from 4, and is back at work, but she still has little interest in seeing friends, low energy in the afternoons and trouble concentrating. She denies suicidal thoughts, plans or intent. Side effects: mild nausea in the first two weeks, now resolved. She is attending a support group but hasn't started individual therapy. Alcohol: one glass of wine a week. No substance use.
Patient Health Questionnaire-9: 13 today (19 at the start of treatment); item 9 (thoughts of self-harm) scored 0.
O: Objective
- Mental status examination: well-groomed and cooperative; good eye contact. Speech normal in rate and volume. Mood "okay, I guess"; affect mildly constricted but reactive. Thought process linear; no delusions. Denies suicidal and homicidal ideation. Insight and judgment good.
- Vital signs: blood pressure 116/72, heart rate 70, weight unchanged.
A: Assessment
Major depressive disorder, single episode, moderate, with partial response to treatment.
Her PHQ-9 has fallen from 19 to 13. Scores of 10 to 14 indicate moderate depression (Kroenke et al., 2001), so she has improved but is not in remission. She is tolerating sertraline and has room to increase the dose.
Evidence on next steps. In the STAR*D trial, adults with nonpsychotic major depression who didn't reach remission moved through up to four treatment steps. Remission rates were 36.8%, 30.6%, 13.7% and 13.0% at steps 1 to 4, and the cumulative remission rate was 67%. People who needed more steps had higher relapse rates during follow-up (Rush et al., 2006). The aim is full remission, not partial improvement, and remission becomes harder to reach with each step, so it's worth optimizing the current step before moving on.
Risk assessment: low acute risk. No suicidal ideation, protective factors include her children and work, and she has no history of attempts.
P: Plan
- Medication: increase sertraline to 150 mg daily, since she has tolerated 100 mg without lasting side effects. If she doesn't reach remission after an adequate trial at this dose, discuss switching or augmenting.
- Psychotherapy: refer for cognitive behavioral therapy; combined treatment is often more effective than medication alone.
- Measurement-based care: repeat the PHQ-9 at each visit, with remission defined as a score below 5.
- Safety: review warning signs and the 988 Suicide & Crisis Lifeline; she agrees to call if her mood worsens or suicidal thoughts appear.
- Lifestyle: regular physical activity and a consistent sleep schedule.
- Follow-up: in 4 weeks, sooner if needed.
References
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A. A., Stewart, J. W., Warden, D., Niederehe, G., Thase, M. E., Lavori, P. W., Lebowitz, B. D., McGrath, P. J., Rosenbaum, J. F., Sackeim, H. A., Kupfer, D. J., Luther, J., & Fava, M. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. American Journal of Psychiatry, 163(11), 1905–1917. https://doi.org/10.1176/ajp.2006.163.11.1905
