Depression — clinical viva (SIGECAPS, suicide risk, SSRI and ECT)

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"A 28-year-old woman reports 3 weeks of low mood, anhedonia, early-morning wakening, weight loss, and thoughts that she would be better off dead. How do you approach her?" ^[1]

Q1: Diagnosis and classification (2 min)

• Define MDD: ≥5 of 9 symptoms for ≥2 weeks, including depressed mood or anhedonia, with impairment, not better explained by substance/medical illness, and no prior mania.^[1]
• Recite SIGECAPS (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicide + Mood).
• Classify by severity (mild / moderate / severe), course (single vs recurrent), and specifier (melancholic, atypical, psychotic, catatonic, peripartum, seasonal).
• Name key differentials: bipolar depression, adjustment disorder, grief, hypothyroidism, anaemia, substance-induced, dementia (elderly), schizoaffective disorder.

Q2: Risk assessment and organic work-up (2 min)

• Structure suicide assessment: ideation → plan → intent → means → protective factors → prior attempts → access to means.
• Red flags for urgent admission: active plan/intent, psychosis, catatonia/refusal of food, severe self-neglect, postpartum infant-harm thoughts.
• Baseline investigations: FBC, U&E, glucose, TFT, B12/folate, LFT; urine drug screen if indicated; pregnancy test in women of childbearing age.
• Always screen for prior hypomania/mania before antidepressants (DIGFAST). ^[1]

Q3: Management ladder (3 min)

• Mild: active monitoring, guided self-help, CBT; consider medication if persistent.
• Moderate–severe: SSRI first-line — e.g. sertraline 50 mg OD (or escitalopram 10 mg, fluoxetine 20 mg) plus CBT.^[2]
• Counsel: delayed benefit 4–6 weeks; early side effects; review within 1–2 weeks for suicidality (especially under 25 years).
• Continuation: treat ≥6–9 months after remission (first episode); longer if recurrent.
• Inadequate response: check adherence → optimise dose → switch class → augment (e.g. lithium, atypical antipsychotic in specialist care).
• ECT indications: severe/psychotic/catatonic depression, high suicide risk, life-threatening refusal of intake, treatment resistance, preference in pregnancy for severe illness.

Q4: Special populations and pitfalls (1–2 min)

• Pregnancy/postpartum: prefer psychological therapy first if mild–moderate; sertraline often preferred if drug needed; always assess infant-harm thoughts and bonding.
• Elderly: start low, go slow; watch hyponatraemia (SIADH with SSRIs); somatic presentation common; exclude dementia/delirium.
• Adolescents: irritability may dominate; combine psychotherapy; close early review for activation/suicidality.
• Pitfalls: missing bipolar switch; prescribing TCA in high-risk overdose patient; discharging without a safety plan; stopping antidepressant abruptly (discontinuation syndrome, especially paroxetine/venlafaxine). ^[1]

Key phrases examiners want

• "Five of nine for two weeks, including mood or anhedonia."
• "Suicide risk is dynamic — reassess every contact."
• "Sertraline 50 mg daily, review in one to two weeks, full effect at four to six weeks."
• "ECT for psychotic, catatonic, or life-threatening depression." ^[1]

References3ShowHide

1. [1]McCarron RM, Shapiro B, Rawles J, Luo J. Depression. Ann Intern Med, 2021.PMID 33971098
2. [2]Mutz J, Vipulananthan V, Carter B, Hurlemann R, Fu CHY, Young AH. Comparative efficacy and acceptability of non-surgical brain stimulation for the acute treatment of major depressive episodes in adults: systematic review and network meta-analysis. BMJ, 2019.PMID 30917990
3. [3]Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet, 2018.PMID 29477251