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Last Updated: 4/30/2014  


  • Ask patients whether they have experienced depressed mood or anhedonia during the last month (PHQ-2).

  • Consider using the four “SALSA” questions to assess for the presence of four symptoms of depression: sleep disturbance, anhedonia, low self-esteem, and change in appetite in patients with a positive PHQ-2. Two of the four symptoms can confirm depression.

  • Use additional instruments, such as the PHQ-9, in patients with symptoms.

  • Recognize the elderly as a high-risk group for depression and screen them appropriately, generally using the Geriatric Depression Scale.

  • Assess the severity of depression and functional impairment using the PHQ-9.

  • Assess suicidal ideation, intent, and risk.

  • Consider screening for hypothyroidism in patients with depression; base other laboratory testing for secondary causes of depression on clinical evaluation.

  • Recognize that the syndrome of major depression can be a presenting feature of other major mental disorders and substance abuse.

  • Refer patients to a psychiatrist when the diagnosis is uncertain or when complex comorbidities or significant suicidal ideation is present, or if a patient does not respond to treatment.

  • Offer psychotherapy to all patients with depression.

  • Consider single-agent antidepressant drug therapy in patients with major depressive disorder, persistent depressive disorder (dysthymia), or both (“double depression”). Treat patients with severe symptoms with an antidepressant.

  • Base choice of antidepressant on side-effect profile.

  • Treat first episodes of depression to achieve complete remission, and continue treatment for 4 to 9 months thereafter.

  • Treat recurrences of major depression with long-term maintenance therapy.

  • Provide patient and family education and inform patients about the expected response time. Create systems of care incorporating collaborative care and/or the chronic care model.

  • Assess patients at 1 to 2 weeks for medication side effects, and at 6 to 8 weeks and 12 weeks for therapeutic response.

DOI: 10.7326/d954
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Author(s) and Disclosures:
Elana Sydney, MD has nothing to disclose. Steven Hahn, MD is a consultant for Pfizer, received honorarium from Pfizer, received grant from Lilly. Robert McCarron, DO has nothing to disclose. Matthew Reed, MD, MSPH has nothing to disclose.

One or more of the present or past ACP Smart Medicine physician editors worked on this module and had nothing to disclose: Davoren Chick, MD, FACP; Deborah Korenstein, MD, FACP; Marjorie Lazoff, MD, FACP; Richard Lynn, MD, FACP.

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