A 60-year-old woman with treatment-resistant depression has been referred for electroconvulsive therapy (ECT) after failing adequate trials of four different antidepressants including augmentation strategies. She has severe depression with psychomotor retardation, significant weight loss, and pervasive guilt. Her family is concerned about potential cognitive side effects of ECT. They ask about factors that might be modified to minimise cognitive adverse effects while maintaining treatment efficacy. Which modification would most effectively reduce cognitive side effects while preserving antidepressant efficacy?

Using unilateral electrode placement on the non-dominant hemisphere rather than bilateral placement

Reducing the electrical dose to just above seizure threshold regardless of electrode placement

Extending the interval between treatments from twice weekly to once weekly throughout the course

Using ultra-brief pulse width stimulation with bilateral electrode placement

Limiting the total number of ECT sessions to a maximum of 6 treatments

A 38-year-old solicitor presents with a 10-week history of low mood, anhedonia, fatigue, and reduced concentration. She describes feeling guilty about her work performance despite no objective evidence of problems. She has prominent anxiety symptoms including worry, restlessness, and muscle tension present most days. Her PHQ-9 is 17 and GAD-7 is 14. She has no past psychiatric history. What is the most appropriate initial pharmacological treatment choice?

Commence sertraline as it effectively treats both depressive and anxiety symptoms

Commence mirtazapine for its combined antidepressant and anxiolytic effects with rapid onset

Commence pregabalin for the generalised anxiety disorder with review to add an antidepressant if depression persists

Commence a low-dose benzodiazepine for anxiety symptoms with an SSRI added after anxiety is controlled

Commence venlafaxine as an SNRI is more effective than SSRIs for mixed anxiety-depression

A 35-year-old woman with panic disorder has been stable on escitalopram 20mg daily for 18 months, remaining panic-free for 12 months. She wishes to discontinue medication as she is planning pregnancy. She previously had severe panic disorder with 8-10 attacks weekly and significant agoraphobic avoidance requiring 6 months off work. She received CBT alongside medication. Which approach to discontinuation carries the optimal balance of minimising withdrawal symptoms while reducing recurrence risk?

Gradually taper over at least 4 weeks while reinstating CBT techniques and monitoring for early signs of recurrence

Discontinue escitalopram abruptly as SSRIs can be safely stopped without tapering due to long half-lives

Reduce by 50% every week for 2 weeks then stop, as escitalopram has relatively low discontinuation syndrome risk

Switch to fluoxetine for 2 weeks before discontinuation due to its longer half-life reducing withdrawal symptoms

Reduce dose by 25% every 2 weeks while commencing a tricyclic antidepressant which is safer in pregnancy

A 52-year-old businessman presents with symptoms of both panic disorder and alcohol dependence. He reports drinking 60-80 units per week for the past 3 years. He experiences 3-4 panic attacks weekly, mostly in the morning, with palpitations, sweating, and tremor. He recognises he uses alcohol to manage his anxiety symptoms. He has no history of seizures or delirium tremens. He is motivated to address both problems. What is the most appropriate initial management strategy?

Manage alcohol withdrawal first using a benzodiazepine-assisted reduction regimen before addressing panic disorder

Commence an SSRI immediately for panic disorder while simultaneously initiating alcohol reduction strategies

Start propranolol for panic symptoms and naltrexone for alcohol dependence simultaneously

Refer to specialist dual diagnosis services before initiating any specific treatment

Commence CBT for panic disorder while the patient continues to drink at current levels to establish therapeutic alliance

A 40-year-old man with generalised anxiety disorder has been receiving high-intensity CBT for 14 weeks. Initially his GAD-7 score was 18, and after 8 sessions it has reduced to 15. He reports using thought challenging techniques and has reduced some avoidance behaviours, but continues to experience significant worry about health and work, with persistent muscle tension and poor sleep. What is the most appropriate next step in management?

Add an SSRI while continuing with psychological therapy to optimise treatment response

Continue CBT for a further 6-8 weeks as response is evident and further improvement is likely

Discontinue CBT and commence an SSRI as first-line pharmacological treatment

Switch to a different psychological intervention such as mindfulness-based cognitive therapy

Refer to specialist mental health services for consideration of pregabalin or duloxetine

A 45-year-old teacher presents with a 9-week history of low mood, anhedonia, reduced energy, and poor concentration affecting her work. She has early morning wakening and has lost 4kg in weight. Her past psychiatric history includes two previous depressive episodes, the first 8 years ago requiring 6 months of citalopram, and the second 3 years ago requiring 18 months of sertraline. She achieved full remission after both episodes. What is the most appropriate duration of antidepressant treatment once remission is achieved in this current episode?

At least 2 years following remission due to the recurrent nature of her depression

6 months following remission, as she previously responded well to this duration

12 months following remission, as recommended for a second depressive episode

Treatment should be continued indefinitely given three episodes of depression

9 months following remission to match the duration of the current episode

Depression for UKMLA AKT: High-Yield Mental Health Lessons

Quick Overview

Depression is a common mental disorder affecting ~5% of UK adults, characterized by persistent low mood and/or anhedonia lasting ≥2 weeks. NICE NG222 emphasizes structured assessment using PHQ-9, stepped care approach, and first-line SSRIs with clear criteria for escalation. Recognition and appropriate management reduce suicide risk and functional impairment.

Core Facts & Concepts

DSM-5 Diagnostic Criteria: ≥5 symptoms for ≥2 weeks including mandatory low mood OR anhedonia, plus:

Sleep disturbance (insomnia/hypersomnia)
Interest loss (anhedonia)
Guilt/worthlessness
Energy deficit (fatigue)
Concentration impairment
Appetite change (weight loss/gain >5%)
Psychomotor agitation/retardation
Suicidal ideation

PHQ-9 Severity Thresholds (NICE NG222):

0-4: Minimal depression
5-9: Mild (watchful waiting, low-intensity psychological interventions)
10-14: Moderate (consider antidepressants + psychological therapy)
15-19: Moderately severe (antidepressants recommended)
20-27: Severe (urgent assessment, consider crisis team referral)

Figure 1: PHQ-9 questionnaire showing 9-item depression screening tool with 4-point Likert scale

First-Line SSRI Selection (NICE NG222):

Sertraline: 50mg OD (best evidence, fewer drug interactions)
Citalopram: 20mg OD (max 40mg; caution with QTc prolongation)
Fluoxetine: 20mg OD (long half-life, useful for non-adherence concerns)
Review at 2 weeks (suicide risk/tolerance), therapeutic trial = 6-8 weeks

Treatment-Resistant Depression (TRD):

Definition: Inadequate response to ≥2 antidepressants at therapeutic dose for adequate duration
Management: Switch class (SNRI, mirtazapine), augmentation (lithium, antipsychotic), refer psychiatry

Problem-Solving Approach

Step 1: Structured Assessment

PHQ-9 score for severity quantification
Screen for bipolar (prior mania/hypomania), psychosis, substance misuse
Suicide risk assessment (ideation, plans, intent, protective factors)
Medical causes: Hypothyroidism, anaemia, B12/folate deficiency, chronic disease

Step 2: Stepped Care Model (NICE NG222)

Step 1 (PHQ-9 <10): Psychoeducation, sleep hygiene, guided self-help
Step 2 (PHQ-9 10-14): Low-intensity CBT, computerized CBT, group therapy
Step 3 (PHQ-9 ≥15): Antidepressant + high-intensity psychological therapy (CBT/IPT)
Step 4: Crisis team, psychiatry referral, consider ECT

Figure 2: Clinical decision flowchart for depression management showing stepped care approach

Step 3: SSRI Initiation & Monitoring

Start sertraline 50mg OD (or citalopram 20mg, fluoxetine 20mg)
Review 2 weeks: Tolerability, suicide risk (increased early risk <25 years)
Review 6-8 weeks: Response assessment (aim 50% PHQ-9 reduction)
If inadequate response: Increase dose → Switch SSRI → Switch class → TRD pathway

🚩 Red Flags for Urgent Referral:

Active suicidal plans with high intent/low protective factors
Psychotic symptoms (hallucinations, delusions)
Severe self-neglect or functional impairment
Safeguarding concerns (children/vulnerable adults)

Analysis Framework

Differential Diagnosis Table:

Condition	Key Discriminators
Bipolar Depression	Prior mania/hypomania, family history, early onset <25y
Adjustment Disorder	Clear stressor, symptoms <6 months, less severe
Dysthymia (PDD)	Chronic low mood ≥2 years, fewer symptoms than MDD
Hypothyroidism	Weight gain, cold intolerance, bradycardia, ↑TSH
Substance-Induced	Alcohol/cannabis misuse, symptom onset with substance use
Grief Reaction	Recent bereavement, waves of sadness, preserves self-esteem

SSRI vs SNRI Comparison:

Feature	SSRI (Sertraline)	SNRI (Venlafaxine)
First-line	✓ Yes (NICE NG222)	Second-line
Efficacy	Moderate-severe depression	TRD, neuropathic pain
Side effects	GI upset, sexual dysfunction	Hypertension, discontinuation syndrome
Monitoring	Minimal	BP monitoring required

Visual Aid

Secondary Care Referral Criteria:

Indication	Urgency
Active suicide plan + high intent	Same day crisis team
Psychotic depression	Urgent psychiatry (within 2 weeks)
Treatment-resistant (≥2 failed trials)	Routine psychiatry referral
Severe self-neglect/safeguarding	Urgent multidisciplinary assessment

Key Points Summary

✓ PHQ-9 thresholds: 5-9 mild, 10-14 moderate (consider SSRI), ≥15 severe (SSRI recommended)

✓ First-line SSRI: Sertraline 50mg OD (best evidence per NICE NG222); review at 2 weeks (suicide risk), 6-8 weeks (efficacy)

✓ TRD definition: Inadequate response to ≥2 antidepressants at therapeutic dose for adequate duration → switch class or augment

✓ Urgent referral criteria: Active suicidal plans, psychotic symptoms, severe self-neglect, safeguarding concerns

✓ Stepped care: Match intensity to severity (low-intensity CBT for mild, high-intensity + SSRI for severe)

✓ Common pitfall: Starting antidepressants without suicide risk assessment or 2-week follow-up (increased risk <25 years)

✓ Screen for bipolar: Prior mania/hypomania before SSRI initiation (risk of manic switch)

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Depression