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

Opening stem

"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]

References

[1]McCarron RM, Shapiro B, Rawles J, Luo J. Depression. Ann Intern Med, 2021.PMID 33971098
[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]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

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]

References

[1]McCarron RM, Shapiro B, Rawles J, Luo J. Depression. Ann Intern Med, 2021.PMID 33971098
[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]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