Depression and anxiety disorders are among the most common psychiatric conditions you'll encounter on CCS outpatient clinic cases. Examiners expect you to screen for depression using validated tools like the PHQ-9, diagnose major depressive disorder or generalized anxiety disorder, select appropriate SSRI therapy, counsel on side effects and monitoring, screen for suicidal ideation with appropriate safety assessment, and coordinate referral to therapy. Unlike acute medical emergencies, psychiatric cases require careful history-taking, thoughtful medication selection, and patient education about the chronic nature of these conditions. This article is your complete clinical guide to passing CCS depression and anxiety cases with confidence.
Depression Screening and Diagnosis
PHQ-9: The Primary Screening Tool
The Patient Health Questionnaire-9 (PHQ-9) is a 9-item depression screening tool that takes 2-3 minutes and is validated for major depressive disorder.
PHQ-9 Questions (on CCS, patient responses will be provided):
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you're a failure
7. Trouble concentrating on things
8. Moving or speaking so slowly people have noticed, OR so fidgety you can't sit still
9. Thoughts that you'd be better off dead, or of hurting yourself
Scoring:
• 0 = Not at all
• 1 = Several days
• 2 = More than half the days
• 3 = Nearly every day
• Total score: Sum all 9 items (0-27)
Interpretation:
• 0-4: Minimal depression
• 5-9: Mild depression
• 10-14: Moderate depression
• 15-19: Moderately severe depression
• 20-27: Severe depression
Score ≥10 = Presumptive diagnosis of major depressive disorder (with PHQ-9 item #9 being key marker of risk)
> Study Tip: The StudyCCS question bank includes 10+ depression cases where you must administer/interpret PHQ-9, assess suicidal ideation, choose appropriate SSRI therapy, and monitor response. Real-time grading shows which assessment questions earn points.
Diagnostic Criteria for Major Depressive Disorder (DSM-5)
A patient meets criteria for MDD if they have ≥5 of the following symptoms during a 2-week period, with at least one being depressed mood or loss of interest/pleasure:
1. Depressed mood (most of the day, nearly every day)
2. Loss of interest or pleasure in activities (anhedonia)
3. Significant weight/appetite change
4. Sleep disturbance (insomnia or hypersomnia)
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or guilt
8. Reduced ability to concentrate or make decisions
9. Recurrent thoughts of death or suicide
Specifiers (document on CCS):
• Single episode vs. recurrent: First episode or ≥2 episodes?
• Severity: Mild (5-6 symptoms), moderate (7-8 symptoms), severe (9+ symptoms)
• With or without psychotic features: Does patient have delusions or hallucinations?
Ruling Out Medical Causes (Differential Diagnosis)
Before diagnosing primary depression, rule out medical causes:
• Hypothyroidism: Check TSH (fatigue, weight gain, mood symptoms mimic depression)
• Anemia: Check CBC (fatigue, low energy)
• Vitamin B12 deficiency: Check B12 level (fatigue, cognitive symptoms, mood changes)
• Medication-induced: SSRIs can paradoxically worsen mood early; steroids cause mood elevation then crash; beta-blockers can worsen depression
• Substance use: Alcohol, cocaine, amphetamines can cause mood symptoms
• Bipolar disorder: Ask about history of manic/hypomanic episodes (elevated mood, decreased need for sleep, racing thoughts, increased talkativeness)
Order on CCS:
"TSH, CBC, B12 level to rule out medical causes of depression. Review medication list for drugs that could worsen mood. Ask about history of manic/hypomanic episodes to assess for bipolar disorder."
Suicidal Ideation Assessment: The Critical Safety Assessment
This is non-negotiable on every depression case. You must assess suicidal risk.
Suicidal Ideation Screening
Ask directly and specifically:
• "Have you thought about harming yourself or ending your life?" (yes/no)
• If yes: "How often have you had these thoughts?" (daily, weekly, occasionally)
• "Do you have a plan for how you would do it?" (presence of plan = increased risk)
• "Do you have access to the means?" (e.g., gun in house, medications)
• "Do you intend to act on these thoughts?" (intent = highest risk)
Risk Stratification:
• Low risk: Occasional thoughts, no plan, no intent, denies access to means
• Moderate risk: Frequent thoughts, vague plan, no clear intent, has means
• High risk: Frequent/persistent thoughts, specific detailed plan, clear intent, available means, recent attempt/gesture
Safety Assessment and Management
Low risk:
• Provide crisis hotline number (988 Suicide & Crisis Lifeline)
• Brief supportive therapy, start antidepressant, schedule close follow-up (1-2 weeks)
• Involve family/support system
• Order on CCS: "Screen for suicidal ideation: Patient denies current intent. Provide 988 crisis hotline. Schedule follow-up in 1 week. Involve family."
Moderate-to-high risk:
• Psychiatric hospitalization or partial hospitalization program (PHP)
• Safety plan: Remove access to means (guns locked, medications stored safely)
• Involve family/emergency contacts
• Order on CCS: "Psychiatric safety assessment indicates moderate-to-high suicide risk. Recommend inpatient psychiatric hospitalization vs. partial hospitalization program. Contact psychiatry. Do NOT discharge home."
If active suicidal intent with plan and means:
• Call 911 or emergency services immediately
• Do not leave patient unattended
• Order on CCS: "Patient endorses active suicidal ideation with specific plan and intent. Emergently contact psychiatry. Consider involuntary hold if patient refuses hospitalization. Safety is paramount."
> Practice Alert: Suicidal ideation assessment is tested on nearly every CCS depression case. The StudyCCS question bank includes realistic cases where your safety assessment determines disposition and score. Asking the right questions and escalating appropriately earns full points.
SSRI Selection and Initiation
SSRIs are first-line antidepressants for major depressive disorder and generalized anxiety disorder.
Choosing the Right SSRI
Common SSRIs (all similarly effective; choose based on side effect profile and drug interactions):
Sertraline (Zoloft)
• Advantages: First-line, once-daily, minimal drug interactions, well studied, generic (cheap)
• Disadvantages: Sexual dysfunction common
• Dosing: Start 50 mg daily; target 100-200 mg daily (range 50-300 mg)
• Best for: Most patients; good general choice
Escitalopram (Lexapro)
• Advantages: Well tolerated, fewer side effects than citalopram, once-daily
• Disadvantages: Cost (newer), less drug interaction data than sertraline
• Dosing: Start 10 mg daily; target 20-30 mg daily (max 40 mg, but limit to 20 mg if age >60)
• Best for: Older adults, patients intolerant to other SSRIs
Fluoxetine (Prozac)
• Advantages: Longest half-life (allows less frequent dosing), once-daily, generic
• Disadvantages: Sexual dysfunction common, takes longer to reach steady state, more drug interactions
• Dosing: Start 10-20 mg daily; target 40-80 mg daily (range 20-80 mg)
• Best for: Patients with irregular medication adherence (long half-life = forgiveness factor)
Paroxetine (Paxil)
• Advantages: Once-daily, approved for multiple anxiety disorders
• Disadvantages: More sedating, sexual dysfunction common, more withdrawal symptoms, more weight gain
• Dosing: Start 10-20 mg daily; target 40-50 mg daily (range 20-80 mg)
• Best for: Anxiety-predominant depression, patients who need sedation
Citalopram (Celexa)
• Advantages: Generic, cheap
• Disadvantages: QT prolongation risk at higher doses, less commonly used now
• Dosing: Start 10-20 mg daily; max 20 mg daily if age >60 (QT risk)
• Best for: Older adults (at lower doses only)
SSRI Initiation Protocol on CCS
Order on CCS:
"Start sertraline 50 mg daily. Can increase by 50 mg q1-2 weeks to target 100-200 mg daily based on response. Counsel: Takes 4-6 weeks for full effect; may feel worse initially. Advise on sexual side effects, sleep changes. Schedule follow-up in 2 weeks to assess."
Patient education:
• "Takes 4-6 weeks to feel better. Don't stop early even if no improvement initially."
• "May feel slightly worse first 1-2 weeks (akathisia, increased anxiety) before improvement."
• "Sexual side effects possible (decreased libido, delayed ejaculation, anorgasmia)—discuss options if problematic."
• "Some weight gain possible, usually 5-10 lbs."
• "Avoid alcohol (increases sedation, impairs judgment)."
• "Don't abruptly stop (withdrawal syndrome: dizziness, nausea, anxiety, electric shock-like sensations); taper if discontinuing."
Monitoring and Dose Escalation
Timeline for response:
• Week 1-2: Side effects may appear; minimal mood improvement; reassure and continue
• Week 3-4: Side effects usually diminish; mood may begin improving
• Week 6-8: Full therapeutic effect; if inadequate response, escalate dose
If inadequate response at 6 weeks:
• Option 1: Increase dose (e.g., sertraline from 100 to 150 mg)
• Option 2: Switch to different SSRI (if side effects intolerable)
• Option 3: Augmentation (add low-dose aripiprazole, buspirone, or bupropion)
• Option 4: Refer to psychiatrist (if complex case)
Order on CCS (if inadequate response):
"Patient has taken sertraline 100 mg daily for 8 weeks with minimal improvement. Escalate to sertraline 150 mg daily. Reassess in 2 weeks. If continued inadequate response, consider augmentation or psychiatry referral."
> Study Tip: The StudyCCS question bank includes 8+ SSRI initiation and escalation cases where you must choose the right agent, counsel the patient on side effects and timeline, and make escalation decisions. Real-time grading teaches you the exact monitoring intervals and dose adjustments.
Generalized Anxiety Disorder (GAD): Diagnosis and Management
Generalized anxiety disorder is characterized by persistent excessive worry and anxiety. It frequently co-occurs with depression.
GAD Diagnostic Criteria
Patient must have excessive anxiety and worry about multiple aspects of daily life for ≥6 months:
1. Excessive worry: About multiple topics (work, finances, health, family)
2. Difficult to control: Patient recognizes worry is excessive
3. Associated with ≥3 of the following:
◦ Restlessness or feeling keyed up
◦ Easily fatigued
◦ Difficulty concentrating
◦ Irritability
◦ Muscle tension
◦ Sleep disturbance
4. Causes significant distress or impairment in functioning
GAD Severity (Generalized Anxiety Disorder-7 Scale)
GAD-7 Score interpretation:
• 0-4: Minimal anxiety
• 5-9: Mild anxiety
• 10-14: Moderate anxiety
• 15-21: Severe anxiety
Score ≥10 = Presumptive GAD diagnosis
GAD Treatment
First-line: SSRI (same agents used for depression)
• Sertraline 50-200 mg daily
• Escitalopram 10-40 mg daily
• Paroxetine 20-60 mg daily (FDA-approved for GAD)
Timeline: 4-6 weeks for full effect (same as depression)
Non-pharmacologic:
• Cognitive-behavioral therapy (CBT) first-line; refer to therapist
• Relaxation techniques, mindfulness, meditation
• Exercise, sleep hygiene
If inadequate response to SSRI:
• Can add buspirone (5-30 mg daily) as augmentation
• Or add low-dose propranolol for somatic symptoms (tremor, palpitations)
• Avoid benzodiazepines long-term (risk of dependence)
Order on CCS:
"GAD diagnosed. Start sertraline 50 mg daily, target 100-200 mg. Refer to therapist for cognitive-behavioral therapy. Teach relaxation techniques (diaphragmatic breathing, progressive muscle relaxation). Follow-up in 2 weeks."
Panic Disorder: Recognition and Management
Panic disorder is characterized by recurrent unexpected panic attacks and persistent worry about future attacks.
Panic Attack Symptoms
• Sudden onset of intense fear/dread (peak within 5-10 minutes)
• Physical symptoms: Chest pain, dyspnea, palpitations, tremor, dizziness, nausea, fear of dying or losing control
• Often misdiagnosed as cardiac (ACS) or respiratory emergency
Panic Disorder Diagnosis
• ≥2 unexpected panic attacks
• Persistent worry about future attacks or change in behavior to avoid triggers
• Not better explained by substance use, medical condition, or other psychiatric disorder
Panic Disorder Treatment
First-line: SSRI
• Same SSRIs as depression/anxiety
• Takes 2-4 weeks for benefit; requires patience from patient
CBT: Highly effective; first-line non-pharmacologic therapy
Crisis management:
• Teach patient to recognize panic attack is not cardiac emergency
• Breathing exercises: Slow diaphragmatic breathing reduces hyperventilation
• Grounding techniques: 5 senses exercise (name 5 things you see, 4 you hear, 3 you feel, 2 you smell, 1 you taste)
• Avoid emergency department visits for panic attacks (reinforces fear)
Short-term benzodiazepines (controversy):
• Effective for acute panic symptom relief (alprazolam 0.5-1 mg PO, lorazepam 1-2 mg PO)
• Risk: Dependence, abuse, tolerance
• Most experts: Start SSRI + therapy; use benzodiazepines only short-term (2-4 weeks) while SSRI takes effect
• On CCS: If panic attack acutely, can give lorazepam for symptom relief, but emphasize SSRI initiation and therapy
Order on CCS:
"Panic disorder. Start sertraline 50 mg daily. Teach breathing exercises and grounding techniques. Refer to therapist for CBT. For acute panic: Lorazepam 1 mg PO as needed, but plan to discontinue within 4 weeks as SSRI takes effect. Reassure chest pain workup is negative; this is panic, not cardiac."
Substance Use Screening in Psychiatric Cases
Substance use frequently co-occurs with depression and anxiety. You must screen.
CAGE Screening (Alcohol)
• C: Have you felt the need to Cut down on drinking?
• A: Have people Annoyed you by criticizing your drinking?
• G: Have you felt bad or Guilty about your drinking?
• E: Have you had an Eye-opener (drink first thing in morning)?
≥2 positive = alcohol abuse/dependence; refer to addiction medicine or AA
Substance Use Disorder Screening
• Ask directly: "Do you use marijuana, cocaine, methamphetamine, opioids, other drugs?"
• "How often? How much? When did you last use?"
• UDS (urine drug screen) if suspicion high
• Assess for withdrawal symptoms if heavy use (tremor, anxiety, sweating = suggest withdrawal risk)
Order on CCS:
"Screen for substance use with CAGE and direct questioning. Urine drug screen. If opioid use, discuss options (medication-assisted treatment with buprenorphine vs. abstinence-based program). Refer to addiction medicine."
Don't-Miss Diagnoses in Psychiatric Cases
• Bipolar disorder misdiagnosed as unipolar depression: Ask about manic/hypomanic episodes (elevated mood, decreased need for sleep, racing thoughts, impulsive behavior). Starting SSRI without mood stabilizer can trigger manic episode. Refer to psychiatry if suspected.
• Psychosis: Delusions or hallucinations suggest psychotic depression or other psychotic disorder (schizophrenia). Requires antipsychotic therapy, not SSRI alone. Refer to psychiatry.
• Medical cause of depression: Hypothyroidism, anemia, B12 deficiency, medication side effect. Always check baseline labs.
• Suicidal crisis missed: Underestimating suicide risk; not hospitalizing high-risk patient. Safety assessment is mandatory on every case.
• Medication-induced depression: SSRIs can worsen mood initially; steroids can cause depression; beta-blockers linked to mood symptoms. Review medication list.
• Withdrawal syndrome: Patient stops SSRI abruptly, develops dizziness, nausea, anxiety, electric shock sensation. Counsel on gradual taper.
Complete Order Set: Depression/Anxiety Case
New Diagnosis Depression or Anxiety:
• Administer PHQ-9 (depression) or GAD-7 (anxiety)
• Labs: TSH, CBC, B12 level (rule out medical causes)
• Assess suicidal ideation directly; document safety assessment
• Review medication list (check for mood-worsening drugs)
• Screen for substance use: CAGE (alcohol), direct questioning (other drugs), consider UDS
• Assess for bipolar disorder: Ask about manic/hypomanic episodes
• Start SSRI: Sertraline 50 mg daily (or escitalopram 10 mg daily if older/intolerant)
• Counsel: 4-6 week timeline, side effects, avoid abrupt discontinuation
• Refer to therapy: CBT or counselor
• Schedule follow-up in 2 weeks to assess side effects, mood, suicidal ideation
• If high suicide risk: Psychiatry consultation, consider hospitalization
Follow-up Visit (After 4-6 Weeks):
• Reassess mood with PHQ-9 (or anxiety with GAD-7)
• If inadequate response: Escalate dose or switch SSRI
• If responding: Continue current dose; monitor long-term
• If side effects intolerable: Switch to different SSRI
• Screen for suicidal ideation at each visit
• Encourage continued therapy
Discontinuation (If Remission Achieved):
• Continue SSRI ≥6-12 months for first episode (longer if recurrent)
• Taper slowly over 4-8 weeks if discontinuing (prevent withdrawal syndrome)
• Monitor for relapse; reinitiate quickly if symptoms return
• Order on CCS: "Patient in remission for 1 year on sertraline. Plan slow taper: Reduce to 100 mg x2 weeks, then 50 mg x2 weeks, then discontinue. Monitor for relapse."
2-Minute Screen: Depression/Anxiety Case Recognition
You see a psychiatric case. Quick assessment:
Key information to extract:
• Chief complaint: "Feeling sad," "worried all the time," "can't sleep"
• Duration: How long has this been going on? (≥2 weeks = likely mood disorder)
• Suicidal ideation: Does patient mention wanting to harm self? (CRITICAL—must ask directly)
• Current medications: Is patient already on an SSRI? If so, how long, what dose?
• Triggers: Recent loss, stressor, trauma?
Your 2-minute action plan:
1. Administer PHQ-9 or GAD-7: Get a score to quantify severity.
2. Ask about suicidal ideation: "Have you thought about harming yourself?" If yes, assess plan/intent.
3. Rule out medical causes: TSH, CBC, B12. Ask about medications (steroids, beta-blockers).
4. Screen for bipolar: Ask about manic/hypomanic episodes.
5. Assess substance use: CAGE, direct questioning, consider UDS.
6. Start SSRI if indicated: Sertraline 50 mg or escitalopram 10 mg.
7. Refer to therapy: CBT or counselor.
8. Schedule follow-up: 2 weeks to assess side effects and early response.
Ready to Practice?
The StudyCCS question bank includes 20+ psychiatric cases covering depression, anxiety, panic disorder, and suicidal ideation. Each case teaches you the exact screening questions, safety assessment protocol, SSRI selection and dosing, and follow-up timing. Cases include complex scenarios like depression with suicidal ideation requiring hospitalization, and cases where medication escalation or switch is needed. Real-time grading shows you exactly which assessment questions and management decisions earn points. Practice a case today and build the clinical judgment needed to pass CCS psychiatric cases on exam day.
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