A 38-year-old woman presents with a 3-week history of depressed mood, anhedonia, insomnia, and feelings of worthlessness. She denies suicidal ideation. Physical examination and basic metabolic panel are normal. She is not on any medications. What is the most appropriate next step in management?

Question

Accepted Answer

A. Start selective serotonin reuptake inhibitor (SSRI) monotherapy. ## Clinical Assessment & Treatment Initiation

**Key Point:** This patient meets DSM-5 criteria for Major Depressive Disorder (MDD) with moderate severity (3 weeks duration, core symptoms present, no psychotic features, no suicidal ideation, no medical contraindications). First-line pharmacotherapy is indicated.

### Why SSRI Monotherapy is Correct

**High-Yield:** SSRIs are first-line agents for MDD in non-psychotic, non-suicidal presentations because of:
  - Efficacy comparable to tricyclic antidepressants (TCAs)
  - Superior tolerability and safety profile
  - Low lethality in overdose
  - No dietary restrictions (unlike MAOIs)
  - Minimal drug interactions

**Clinical Pearl:** The patient has no contraindications to outpatient pharmacotherapy:
  - No active suicidal ideation
  - No psychotic features
  - No medical comorbidities requiring inpatient management
  - Stable social support (implied by outpatient presentation)

### Expected Timeline

| Phase | Duration | Monitoring |
|-------|----------|------------|
| Initiation | Week 1–2 | Baseline assessment, side effect counseling |
| Titration | Week 2–4 | Weekly contact (phone/visit) for safety |
| Response evaluation | Week 4–6 | Clinical improvement expected by week 4–6 |
| Optimization | Week 6–12 | Dose adjustment if partial response |

**Mnemonic:** **SSRI START** = **S**afe, **S**elective, **R**eliable, **I**nitial choice; **S**urvivable in overdose, **T**olerable, **A**ccesible, **R**apid onset, **T**ested first-line

### Counseling Points
- Onset of action: 2–4 weeks (not immediate)
- Common early side effects: nausea, insomnia, sexual dysfunction (often transient)
- Importance of adherence and regular follow-up
- No abrupt discontinuation (risk of discontinuation syndrome)

Answer

B. Refer for electroconvulsive therapy (ECT)

Answer

C. Prescribe benzodiazepine and arrange follow-up in 4 weeks

Answer

D. Admit to psychiatric inpatient unit for observation

A 38-year-old woman presents with a 3-week history of depressed mood, anhedonia, insomnia, and feelings of worthlessness. She denies suicidal ideation. Physical examination and basic metabolic panel are normal. She is not on any medications. What is the most appropriate next step in management?

Explanation

Clinical Assessment & Treatment Initiation

Why SSRI Monotherapy is Correct

Expected Timeline

Counseling Points

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Phase	Duration	Monitoring
Initiation	Week 1–2	Baseline assessment, side effect counseling
Titration	Week 2–4	Weekly contact (phone/visit) for safety
Response evaluation	Week 4–6	Clinical improvement expected by week 4–6
Optimization	Week 6–12	Dose adjustment if partial response