NUR 7632 Module 1 Adult Depression Case: PHQ-9 Severity, First Antidepressant and STAR*D Example

A PHQ-9 of 18 on a Night Shift: Choosing a First Antidepressant and Planning the Next Step for a 34-Year-Old Supervisor

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7632: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Adult Population, Part A

Mentor Name

Month Day, Year

A PHQ-9 of 18 on a Night Shift: Choosing a First Antidepressant and Planning the Next Step for a 34-Year-Old Supervisor

Three Months of Gray

Luis is an invented patient, 34 years old, who supervises the night crew at a distribution warehouse in New Brunswick. Over three months he has lost interest in coaching his son's soccer team, sleeps four or five broken hours after his shift, has lost twelve pounds without trying and finds he rereads the same delivery schedule several times. He feels he is letting his crew down and says that sometimes he wishes he would not wake up, though he has no plan or intent and has never harmed himself. His wife urged him to come after he snapped at his son over homework.

He has no history of mania or of elevated periods with little need for sleep, which his wife confirms. He drinks two beers on days off and uses no drugs. His thyroid tests, blood count and metabolic panel from his primary care visit last month are normal. His mother had depression treated with sertraline. He has never taken psychiatric medicine and prefers a plan that will not leave him drowsy on the forklift floor.

His work pattern shapes the whole plan. His shifts run overnight, Sunday through Thursday, drives a forklift for part of each shift and signs off on safety checks for his crew. Any medicine that slows his reactions is a hazard to him and to others, and any appointment must fit the hours when he is awake. He wants the diagnosis kept from his employer, and that wish is honored, though he accepts that a brief leave letter could be written later if needed.

Measuring Severity

Kroenke et al. (2001) tested the nine-item Patient Health Questionnaire with 6,000 patients in primary care and obstetrics clinics, scoring each symptom from 0 for not at all to 3 for nearly every day. Checked against interviews by mental health professionals, a total at or above 10 caught 88 percent of major depression and correctly cleared 88 percent of those without it, and the authors set bands for mild, moderate, moderately severe and severe illness starting at 5, 10, 15 and 20. As scores rose, function, sick days and clinic use all worsened. Luis totals 18, in the moderately severe band, and marks a 1 on item 9, the question about being better off dead.

That last item leads to a direct risk assessment. His thoughts are passive, he has reasons to live in his wife and son, he has no firearms at home and no prior attempts. Risk is judged low, and a safety plan with crisis numbers is written with him.

Ruling Out Bipolar Disorder and Medical Causes

Before any antidepressant, the history for mania or hypomania is taken from Luis and his wife, since an antidepressant alone can destabilize bipolar disorder. No such history exists. His normal thyroid and blood tests, absence of new medicines and limited alcohol use make a medical or substance cause unlikely. His sleep problem is partly from shift work, which is noted as a factor to address rather than the cause of the whole picture.

Choosing the First Medicine

Cipriani et al. (2018) combined 522 double-blind trials of 21 antidepressants in nearly 116,500 adults with major depression. Every drug outperformed placebo for response, with effect sizes that ranged from modest to moderate. Escitalopram, mirtazapine, paroxetine, venlafaxine, vortioxetine, agomelatine and amitriptyline were among the more effective, and escitalopram, sertraline, fluoxetine, citalopram, vortioxetine and agomelatine were among the better tolerated, judged by how many people stopped treatment. Most trials lasted eight weeks, so the ranking speaks to the short term.

Escitalopram sits in both the more effective and better tolerated groups, is generic and is not sedating at usual doses, which matters for Luis's safety-sensitive work. Mirtazapine would help sleep and appetite but brings sedation and weight gain. His mother's good response to sertraline is noted as a reasonable alternative.

Starting and Following Up

Escitalopram starts at a low dose each morning and rises after one to two weeks if tolerated. Luis is told what to expect: possible nausea or headache in the first week, sexual side effects that he should report, and benefit that often takes two to four weeks to begin and longer to be complete. Because he is over 24, the boxed warning about suicidal thoughts in young people applies less directly, but the nurse practitioner still phones him after seven days and sees him within a month, scoring the PHQ-9 each time.

Psychotherapy is offered alongside. A therapist with evening hours is found so he can attend before his shift, and the first sessions focus on behavioral activation, rebuilding the soccer coaching and other activities he has dropped. Sleep hygiene for shift workers, with blackout curtains and a fixed sleep window, is reviewed.

If Remission Does Not Come: The STAR*D Steps

Rush et al. (2006) followed 3,671 outpatients with nonpsychotic major depression through up to four treatment steps, beginning with citalopram. Remission rates were 36.8 percent at the first step, 30.6 percent at the second, then 13.7 and 13.0 percent at the third and fourth. Across all steps about two thirds remitted, but those who needed more steps relapsed more often during follow-up. The lesson is that a first medicine often is not enough, that persistence pays and that remission, not partial response, is the target.

For Luis, the plan is written in advance. Should his score still sit above half its starting value once he has had six to eight weeks at a full dose, the choices are a higher dose, a move to sertraline or another drug class, or an added treatment, and therapy carries on through every option. Once remission is reached, he will continue the medicine for at least six to twelve months to lower the chance of relapse.

Measurement keeps the plan honest. The PHQ-9 is repeated at every visit and charted, so that Luis and the nurse practitioner can both see whether the line is falling. A drop of five points or more is treated as a real change, a fall of half or more as response, and a score under 5 as the remission the plan is aiming for. His own markers are tracked too: the nights he sleeps more than six hours, the Saturdays he coaches and the shifts he finishes without rereading a schedule.

Conclusion

Luis has a moderately severe first episode of major depression, measured with the PHQ-9, with low current suicide risk and no bipolar history. Escitalopram, chosen for its balance of benefit and tolerability in a large network analysis and for his work safety, starts alongside behavioral activation and sleep steps. STAR*D shows that persistence through further steps reaches remission for most people, so the next steps are planned before they are needed.

References

Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., Leucht, S., Ruhe, H. G., Turner, E. H., Higgins, J. P. T., Egger, M., Takeshima, N., Hayasaka, Y., Imai, H., Shinohara, K., Tajika, A., Ioannidis, J. P. A., & Geddes, J. R. (2018). 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. The Lancet, 391(10128), 1357-1366. https://doi.org/10.1016/S0140-6736(17)32802-7

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A. A., Stewart, J. W., Warden, D., Niederehe, G., Thase, M. E., Lavori, P. W., Lebowitz, B. D., McGrath, P. J., Rosenbaum, J. F., Sackeim, H. A., Kupfer, D. J., Luther, J., & Fava, M. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. American Journal of Psychiatry, 163(11), 1905-1917. https://doi.org/10.1176/ajp.2006.163.11.1905