Depression on the CCFP exam

Approach

• Ask straight out about thoughts of death, a plan, intent, means and past attempts.
• Weigh what can change: a plan with intent, hopelessness, psychotic symptoms, alcohol or drug use, and recent stress.
• Scales help you ask about suicidal thoughts. They cannot reliably predict an attempt, so use your own judgment.
• Suicidal thoughts with intent to act, or psychotic symptoms: inpatient care is often needed.
• Lower risk: write a safety plan together. List warning signs, coping steps, people to call, and the 9-8-8 crisis line.
• Remove lethal means, such as firearms and stored pills. Book regular follow-up.
• Watch closely in the month after an antidepressant starts or stops. Risk of suicidal behaviour rises then.

Approach

• Know the risk groups: family history of mood disorder, chronic pain or illness, alcohol or drug use, and pregnancy or the year after birth.
• Adults, even those at higher risk: do not screen everyone with a questionnaire and a cut-off score.
• Pregnancy and the year after birth: the Task Force also advises against questionnaire screening for all.
• Instead, ask about mood and well-being at visits. Stay alert to signs of depression.
• These rules do not cover a patient with symptoms, past depression or a current diagnosis. Assess those patients fully.
• When you suspect depression, take a full history. Do not stop at a score.

Approach

• Think of depression when body symptoms persist and the work-up is normal.
• Ask about sleep, appetite, energy, interest and mood. In a child, ask about friends, school and dropped activities.
• Ask what has changed at home or at school. Ask whether the patient is safe at home.
• Chronic pain and depression feed each other. Look for both and treat both.
• Explain how stress can show up in the body. Do not tell the patient it is all in the head.

Approach

• Anxiety disorders affect about 40% to 60% of people with depression. Ask about worry, panic and avoidance.
• Substance use, attention deficit hyperactivity disorder (ADHD) and personality disorders each affect about 10% to 30%.
• Ask about past highs: days of little sleep, high energy and racing thoughts.
• Ask about trauma and post-traumatic stress disorder. Both add to suicide risk.
• Cognitive behavioural therapy (CBT) helps depression with anxiety, substance use or ADHD. Antidepressants still work when other conditions are present.
• With a personality disorder, plan a longer course of CBT: 16 to 20 sessions.

Approach

• Mild: psychotherapy first, if you can get it. Exercise or guided online CBT also help.
• Moderate: structured therapy or an antidepressant. Think about both together.
• Severe: an antidepressant plus therapy. With psychotic features, add an atypical antipsychotic and refer.
• First-line therapies: CBT, interpersonal therapy (work on relationships and roles) and behavioural activation (planning rewarding activities). Aim for 12 to 16 sessions.
• Exercise: supervised, 30 to 40 minutes, 3 to 4 times a week, for at least 9 weeks.
• Track symptoms with a scale every 2 to 4 weeks at first. Ask about suicidal thoughts at each visit.
• Set goals together, such as sleep, activity and work. Offer the 9-8-8 crisis line and community supports.

Approach

• Take a medical history and do a targeted exam for illness that mimics depression.
• Order a complete blood count (CBC) and thyroid-stimulating hormone (TSH). Both are cheap and find anemia and thyroid disease.
• Add other blood tests only when the history or exam points to another illness.
• No routine electrocardiogram (ECG), brain wave test (EEG) or brain imaging. Consider an ECG if the patient has heart disease and starts a drug that can upset heart rhythm.
• Depression that starts late in life: brain imaging may be considered.
• Look harder in older adults and in patients who are hard to assess.

Approach

• Ask about physical, sexual and emotional abuse, now and in the past. Include abuse seen and abuse done.
• Childhood maltreatment is often not offered. Ask gently, and use a trauma-informed approach.
• Ask about alcohol, cannabis and other drugs.
• Alcohol use disorder and depression often go together. Work out what part alcohol plays, and treat both at once.
• Do not routinely give an antidepressant for alcohol use disorder alone. Use one for a lasting moderate to severe depression or anxiety disorder.
• Cannabis worsens depression outcomes. It is not a treatment for depression.
• A child at risk of abuse must be reported to child protection.

Approach

• Count symptoms and check function.
• If major depression criteria are met, call it major depression, even after a stressor.
• Persistent depressive disorder (dysthymia): 2 or more symptoms for more than 2 years, often below the bar for major depression.
• Grief is a normal process. Severe or long grief raises the risk of a depressive episode, so follow up.

Approach

• Check adherence, the dose, and how long the drug has been taken.
• Ask about past highs. A missed bipolar disorder is one reason for poor response.
• Look for anxiety, ADHD, post-traumatic stress, substance use, personality disorder and sleep apnea.
• Ask about cannabis and alcohol. Cannabis worsens depression outcomes.
• Look again for a physical cause if new signs appear.
• Hallucinations or fixed false beliefs with mood change: think of psychotic depression or schizoaffective disorder, and refer.

Approach

• Depression can show as aches, low energy or tiredness more than low mood.
• Ask about emotional, cognitive and body symptoms, not mood alone.
• Depression that starts late in life: look for a physical or brain cause. Brain imaging may be considered.
• Ask family or teachers what has changed, and when.

Approach

• Choose by past response, side effects, other drugs and overdose risk. Tricyclics are more dangerous in overdose than SSRIs (selective serotonin reuptake inhibitors).
• Check interactions. Fluoxetine and paroxetine block a liver enzyme (CYP2D6). An SSRI with an anti-inflammatory raises bleeding risk; with a diuretic, low sodium.
• Ask about herbal remedies, alcohol and cannabis. St John's wort speeds the breakdown of many drugs and may add serotonin risk with an SSRI.
• Ask about side effects within 2 weeks of starting. Check sodium in adults 60 and over.
• Expect at least 20% improvement by 2 to 4 weeks. No improvement by 4 weeks: raise the dose or switch.
• Partial response, well tolerated: optimize the dose, then add aripiprazole or brexpiprazole. No response or poor tolerance: switch.
• After remission, continue 6 to 12 months, or 2 years or more with risk factors. Taper over weeks to months; fluoxetine needs no taper.

Approach

• Recovery means function, not just fewer symptoms. Ask how the patient copes with daily tasks.
• Ask about leftover symptoms: focus, energy, sleep and memory.
• Ask about job strain and job insecurity. Both add to the risk of depression.
• Keep treating and reviewing after the return.