🏅Your Path to Certification
Earn your way up three evidence-based tiers. Each builds on the last. Finish all three and receive your Certified Prepared Patient · Depression badge and printable certificate, recognized across the FFH Network.
Aware · Identity: Self-Advocate
You know your body and your condition. Layer 1 — Condition Literacy.
- Complete Modules 1–4 (Condition Literacy)
- Pass the "What Depression Is" quiz (≥80%)
- Identify your type (MDD / persistent / postpartum / SAD / bipolar depression / treatment-resistant), your PHQ-9 baseline + 4-week trend, your treatment plan (therapy + medication + lifestyle), and your written safety plan with 988 / Crisis Text Line
- Build your weekly PHQ-9 + sleep/energy/anhedonia tracker with the FFH "Notice and Name" framework
Active · Identity: Care Team Member
You partner with your team and navigate the system. Layer 2 — Care & System Literacy.
- Complete Modules 5–7 (Make Every Visit Count · When to Call vs ED · Comorbidity Awareness)
- Demonstrate teach-back on your treatment plan, the 4–6 week wait for med effect, withdrawal-tapering rule, and your "when to call vs 988 vs ED" decision rule
- Complete one "great visit" prep + debrief
- Build your written safety plan + Care Team card; lethal-means safety conversation complete (firearms, medications)
- Successfully resolve one prior auth (e.g., for esketamine / TMS / brand-name antidepressant), copay-help application, or behavioral-health care-navigator engagement; OR file a Mental Health Parity (MHPAEA) complaint if denied
Certified Prepared Patient · Identity: Ambassador
You teach, mentor, fight stigma, and shape research & policy. Layer 3 — Advocacy & Ambassadorship.
- Complete Modules 8–10 (Family & Care Team · Talk to Kids/Partner/Employer + Mentor · Mastery & Graduation)
- Mentor 1 newly-diagnosed person or family via NAMI Peer-to-Peer / Family-to-Family OR present at a faith-community / employer / school / NAMI education session
- Sign the Prepared Patient Pledge
- Complete a written relapse-prevention plan ("what worked, what to watch for"), and (if relevant) advance care planning
- Submit one advocacy action (story, AFSP "Out of the Darkness" walk, mental-health-parity policy comment, lethal-means-safety advocacy, cultural-competence content for men / AA / Latino / AAPI / Indigenous / LGBTQ+ / older-adult communities)
📋Master Pre / Post Assessment
Where You Stand — Confidence Before & After
Seven dimensions of being a Prepared Patient. Answer once at the start of your journey and again at the end. Your goal is to see real growth across understanding, self-management, communication, and optimal utilization — knowing when to call your team, when to use Day Hospital, and when to go to the ER. Your answers stay on this device unless you choose to share with your clinician.
📈 Your Pre→Post Growth
📞Know Who to Call — 988 First in Crisis
Depression care runs as a long arc — diagnosis, treatment-initiation, response (4–6 weeks for medications), remission, and relapse-prevention. Most days are routine. Some days bring side-effect or treatment-adjustment calls. Crisis days bring suicidal thoughts — and the most important thing to know cold is the 988 Lifeline (call or text), the Crisis Text Line (text HOME to 741741), and when to go to the ED. Knowing the right number to call — your behavioral-health team, NAMI HelpLine, 988, or 911 — saves time, dignity, and life. Save these numbers in your phone today. The numbers below are placeholders — your institution will fill in the right ones for you.
🆘 Any suicidal thoughts, intent, plan, or attempt — 988 (call or text), or 911 / ED for active risk
Any thoughts of wanting to die, hurt yourself, or be a burden = call or text 988 immediately. The 988 Suicide & Crisis Lifeline is free, confidential, 24/7. Active suicide attempt or imminent danger = 911 or go to the ED right away. Veterans: 988 then press 1 for the Veterans Crisis Line. Crisis Text Line: text HOME to 741741. Asking about suicidal thoughts does not plant the idea — landmark evidence on this. Lethal-means safety: at peak risk, distance from firearms (safe storage, off-site), lockboxes for medications. Most suicidal crises are time-limited; putting time and distance between the person and means saves lives.
🧭 Worsening symptoms, side effects, treatment questions — call your behavioral-health team before the ED
For worsening PHQ-9 over 2+ weeks, medication side effects (GI, sexual, sleep, weight, BP changes on SNRIs, sudden activation), SSRI/SNRI discontinuation symptoms if a dose was missed (flu-like, dizziness, electric-shock sensations), increased suicidal thoughts in young people in the first 4–6 weeks of an SSRI (close monitoring, do not stop without taper), possible manic switch (suspect bipolar — racing thoughts, decreased sleep need, grandiosity, risky behavior — stop antidepressant; same-day call), or treatment-effect questions (the 4–6 week wait is real), call your [Behavioral Health Triage Line: (555) 123-4567] or [PCP office]. Most issues are addressable in clinic.
💬 Routine questions, refills, scheduling, peer support
Use [MyChart portal] first — most messages answered within 1 business day. For SSRI / SNRI / atypical refills or copay help, call [Pharmacy: (555) 222-9050]. For peer mentoring, family support, and treatment-locator help, call the NAMI HelpLine 1-800-950-6264 — free, real humans, weekdays. For substance + mental health treatment locator (24/7): SAMHSA 1-800-662-HELP (4357). For LGBTQ+ youth: The Trevor Project 1-866-488-7386 or text START to 678678. For perinatal: Postpartum Support International 1-800-944-4773.
🚑 Call 988 (or 911) right away for any of these
Suicidal thoughts · plan + means with intent · active suicide attempt · severe agitation or psychosis · can't be safely managed at home · postpartum psychosis (severe confusion, hallucinations, mania after birth — life-threatening) · serotonin syndrome (fever, agitation, tremor, rigidity, especially with multiple serotonergic meds) — 988 (call or text), or 911 / ED if active risk. Asking does not plant the idea.
📚Condition Literacy & the 10 Prepared Patient Competencies
A Prepared Patient builds three kinds of health literacy — and grows into three identities. Each competency works through the FFH three pillars: Learn It · Live It · Share It.
Advocate for Self
You speak up for your own care, plan, pain, and goals.
Care Team Member
You partner with your team — not above, not below.
Ambassador
You teach, mentor, and shape research, policy & access.
🧬 Condition Literacy Learn It · Tier 1 Aware
"I know my body and my disease." The foundation. Without this, nothing else holds.
What Depression Is
A real medical condition affecting mood, energy, sleep, appetite, thinking, and motivation — not a character flaw, not weakness, not "just being sad." Modern neuroscience: brain networks (default-mode, salience, prefrontal), neuroplasticity, stress-system, circadian rhythm, inflammation. Types: MDD, persistent (dysthymia), postpartum, SAD, bipolar depression, treatment-resistant. Most people who get treatment get better.
Know My Numbers & Risk Factors — PHQ-9
The validated PHQ-9 screen: 9 items, 0–27 total, action bands at 5/10/15/20. Item 9 = same-visit safety conversation regardless of total. Track sleep, energy, anhedonia, suicidal-ideation check-in. Baseline labs: TSH, CBC, B12/folate, vit D, metabolic (rule out medical mimics). Risks: family history, postpartum, chronic illness, trauma, substance use, social-determinant stress. USPSTF: universal screening in primary care.
Lifestyle Force Field — Exercise, Sleep, Diet, Connection, Light, Substance Moderation
Regular exercise (30+ min most days, aerobic + resistance) — proven antidepressant. Sleep 7–9 hrs, regular schedule (CBT-I evidence-based for insomnia). Mediterranean-style diet (SMILES trial). Social connection non-negotiable. Sunlight + light therapy for SAD (10,000 lux, 30 min/morning). Alcohol moderation/abstinence — alcohol is depressogenic. Mindfulness / MBCT for relapse prevention. Behavioral activation: do first, feel second.
Medications + Therapy — All Three Levers
Therapy: CBT, IPT, behavioral activation, MBCT — all evidence-based, first-line for mild-moderate. Medications: SSRIs first-line (sertraline, escitalopram, fluoxetine), SNRIs, atypicals (bupropion, mirtazapine). 4–6 weeks to full effect. Withdrawal is real — taper, don't stop cold. Combination wins for moderate-severe. ALWAYS ask about mania before SSRI start. Esketamine, ECT, TMS for treatment-resistant — destigmatize ECT. ~60–70% respond first-line; ~80% with sequencing.
🤝 Care & System Literacy Live It · Tier 2 Active
"I'm part of the team. I navigate the system." Where most preventable ED visits, decompensation crises, and frustration happen — and where this course pays off the most. Optimal utilization lives here.
Make Every Visit Count — SHARE Approach + Teach-Back
AHRQ SHARE Approach (Seek, Help, Assess, Reach, Evaluate). Teach-back at every visit. 3-question max written priority list. Numbers card + med list + second pair of ears. Oncology visits are complex; preparation multiplies value.
When to Call vs 988 vs ED — ANY Suicidal Thoughts → 988
ANY suicidal thoughts → 988 (call or text). Active attempt or imminent risk → 911/ED. Veterans: 988 then press 1. Asking does not plant the idea. Worsening symptoms, side effects, possible manic switch (suspect bipolar), discontinuation symptoms, increased SI in young people on SSRI start → same-day behavioral-health call. Lethal-means safety: distance from firearms, lockboxes for medications. Most crises are time-limited.
Comorbidity Awareness — Bidirectional Mood-Medical Loop
Depression-specific Module 7. The bidirectional mood-medical loop: depression worsens outcomes in HTN, T2D, CHF, CKD, post-MI, post-stroke, Alzheimer's, MS, brain tumor, cirrhosis; chronic illness raises depression risk substantially (~30–50% prevalence). Lifestyle levers (exercise, sleep, nutrition, social) overlap heavily with depression treatment levers. Cluster module CROSS-REFERENCED (md5 7587a559b24ca8b9bab40b1756475d84), NOT embedded. Plus: anxiety overlap ~50%; substance use; sleep; chronic pain.
📣 Advocacy & Ambassadorship Share It · Tier 3 Certified
"I speak up. I lift others. I shape the future." This is what turns a Prepared Patient into a force multiplier for the whole community.
Family, Caregiver, and the Care Team — Notice and Name + Lethal-Means Safety
The family Ambassador's "Notice and Name" role: short observable changes (sleep, withdrawal, hopelessness, irritability) warrant a check-in question, not a diagnosis. ASK directly about suicidal thoughts when worried — asking does NOT plant the idea. Lethal-means safety at peak risk: distance from firearms (safe storage / off-site), lockboxes for medications. Accompany to appointments. Team: psychiatry + behavioral health (LCSW/psychologist trained in CBT/IPT) + PCP + RN care manager + NAMI peer + family Ambassador + addiction medicine if comorbid + OB/GYN if perinatal + geriatric psych if older + VA if veteran.
Sharing — Talk to Kids, Partner, Employer; Cultural Competence; Mentor
Kids: plain language — "Mom's brain is sick, the doctors are helping, it's not your fault." Partner: Ambassador "Notice and Name"; ASK about suicide directly. Employer: ADA covers depression; FMLA covers treatment leave; MHPAEA protects coverage; EAP is a free entry point. Cultural competence: men, AA, Latino, AAPI, Indigenous, LGBTQ+ youth (Trevor Project 1-866-488-7386), older adults — different presentation, different help-seeking. NAMI Peer-to-Peer / Family-to-Family. AFSP "Out of the Darkness". Honest framing > pep talk.
Mastery & Graduation — Sustained Remission, Relapse Prevention, Peer Mentor
Sustained remission (PHQ-9 <5 for ≥6 months). Written relapse-prevention plan: "what worked, what to watch for" — early warning signs, contact list, escalation rules, lifestyle protectors. Continue treatment per team (don't stop meds without taper). Peer-mentor track via NAMI / AFSP / DBSA / The Trevor Project / Postpartum Support International. The "anxious days happen, but the disorder is in remission" framing. Earn Certified Prepared Patient · Depression.
👥My Care Team
Your team is bigger than just the doctor — and the care partner is part of it. Click any card to edit, or click the + tile to add a new team member. Saved on this device. The Force Field Emergency Card below auto-syncs from this list. Starter roster pre-populated for depression — your institution can edit any row. The Force Field Emergency Card auto-syncs from this list and surfaces 988 + Crisis Text Line.
📖Glossary — words you'll hear
Plain-English definitions for terms doctors and labs use. Tap to expand.
Major Depressive Disorder (MDD)
PHQ-9 (Patient Health Questionnaire-9)
988 Suicide & Crisis Lifeline
Lethal-means safety / counseling
Suicide warning signs (988-WATCH)
Postpartum Depression (PPD)
Seasonal Affective Disorder (SAD)
Bipolar Depression
Treatment-Resistant Depression (TRD)
SSRIs (Selective Serotonin Reuptake Inhibitors)
SNRIs / Atypicals
CBT, IPT, Behavioral Activation, MBCT
ECT (Electroconvulsive Therapy)
Mental Health Parity (MHPAEA)
🧪Screen & Lab Tutor — your PHQ-9 and what your monitoring labs mean
Screen & Lab Tutor — your PHQ-9 and what your monitoring labs mean
In depression, the most important "lab" is the PHQ-9 score and trend — your central dashboard. Plus a baseline workup to rule out medical mimics, and monitoring labs that depend on the medication you're on. Your "normal" may be different from a friend's. Ask your team to write your personal baseline in the column on the right.
| Test / Screen | What it measures | Typical adult range | What to ask if it's off | My baseline |
|---|---|---|---|---|
| PHQ-9 score | The validated 9-item depression screen. Each item 0–3; total 0–27. Action bands: 5/10/15/20 (mild/moderate/moderately severe/severe). Item 9 = same-visit safety conversation regardless of total. Free at phqscreeners.com. | 0–4 minimal · 5–9 mild · 10–14 moderate · 15–19 mod-severe · 20–27 severe | What's my current PHQ-9? Is the trend moving over 4 weeks? What about Item 9? | [fill in] |
| PHQ-9 4-week trend | Direction matters more than any single score. While in active treatment, repeat PHQ-9 weekly. Clinically meaningful response = ≥50% reduction in score; remission = PHQ-9 <5. | Goal: ≥50% reduction by 4–6 weeks; remission <5 | Am I responding? Should we adjust dose or add a treatment? | [fill in] |
| Item 9 check-in | "Thoughts that you would be better off dead, or of hurting yourself in some way" — frequency 0–3. Any positive answer → same-visit safety conversation regardless of total. Document plan, intent, means, and access at every encounter. | Goal: 0 ("not at all"); any positive = conversation | If >0: Should I update my safety plan? Is lethal-means safety in place? | [fill in] |
| EPDS (Edinburgh Postnatal Depression Scale) | The perinatal-specific complement to PHQ-9. 10 items, 0–30 total. Score ≥13 generally warrants further evaluation. Used during pregnancy and postpartum. Item 10 = self-harm flag, like PHQ-9 Item 9. | 0–8 unlikely · 9–12 possible · ≥13 likely | If pregnant/postpartum: am I being screened? With which tool? | [fill in] |
| TSH (thyroid) | Hypothyroidism is a classic medical mimic of depression. Always check at baseline. Hyperthyroidism can mimic anxiety + agitation. Rule out before assuming primary depression. | 0.4–4.0 mIU/L | Has my thyroid been checked? Any hypothyroid pattern? | [fill in] |
| CBC + B12 / folate | Anemia (low hemoglobin) and B12 / folate deficiency can mimic depression. Always check at baseline. Vitamin D deficiency also commonly assessed. | Hgb 12+ W / 13.5+ M · B12 >200 pg/mL · Folate >3 ng/mL · Vit D >30 ng/mL | Are my CBC, B12, folate, and vitamin D normal? | [fill in] |
| Metabolic panel + liver / kidney | Baseline + monitoring for SSRI/SNRI/atypicals. Some agents need adjustment in liver/kidney impairment. Bupropion is renally + hepatically dosed. | Glucose, BUN/Cr, electrolytes, liver enzymes within standard ranges | Are these compatible with my current med? | [fill in] |
| EKG (QTc) — if on citalopram >40 mg or other QT-prolonging meds | Citalopram has a dose-dependent QT-prolongation risk above 40 mg/day. Monitor QTc on EKG. Other antidepressants generally do not require routine EKG. | QTc <450 ms M / <470 ms W | If on citalopram >40 mg: do I need a QTc EKG? | [fill in] |
| BP (if on SNRI) | Venlafaxine and (less so) duloxetine can raise BP modestly, especially at higher doses. Check at baseline and after dose escalations. | <130/80 mmHg | Is my BP stable on my SNRI? | [fill in] |
| Sleep / energy / anhedonia log | Leading indicators that often shift before PHQ-9 totals do. Track sleep hours + quality, energy 0–10, anhedonia (loss of pleasure) 0–10. Behavioral activation tracker can fold in here. | 7–9 hrs sleep · energy 6+/10 · anhedonia 0–2/10 in remission | Are my leading indicators tracking with my PHQ-9 trend? | [fill in] |
| Substance use screen | Alcohol, cannabis, stimulants, sedatives, opioids — all commonly comorbid with depression and complicate treatment. AUDIT (alcohol), DAST-10 (drugs) are validated short screens. | AUDIT <8 (M) / <7 (W) low risk · DAST-10 <3 low risk | Has my substance use been screened? Comorbid SUD changes the plan. | [fill in] |
| Med list with mental-health-aware review | Some medications cause or worsen depression: interferon, isotretinoin, varenicline, some hormonal contraceptives, beta blockers occasionally, corticosteroids. Some have sexual side effects, weight effects, sleep effects worth tracking. Always taper SSRIs/SNRIs — do not stop cold; discontinuation syndrome is real. | Med-by-med review with pharmacist or prescriber | Could any of my meds be worsening my mood? Is the dose right? How do I taper if stopping? | [fill in] |
➕Add-On Modules & Earnable Badges
Stackable modules that match your situation. Complete one to earn an extra badge on your certificate. Your institution can add their own.
📋 Weekly PHQ-9 Self-Administration
The validated 9-item screen, taken weekly while in active treatment. Free at phqscreeners.com or in your patient portal. Plot the trend on a single sheet. Bring to every visit. Item 9 = always a conversation.
🆘 Written Safety Plan + 988 / Crisis Text Line
A 1-page Stanley-Brown-style safety plan: warning signs, internal coping skills, distractions, supportive people, professional contacts (988, Crisis Text Line, behavioral-health team), and lethal-means safety. Print one for the fridge, save one in your phone.
🔒 Lethal-Means Safety (Firearms + Medications)
The single most effective suicide-prevention intervention. Firearms: locked, off-site at peak risk. Medications: lockboxes; only days-of-supply at home. Distance from access at peak risk. Most crises are time-limited. The conversation is hard but life-saving.
📝 Behavioral Activation Worksheet
Schedule pleasurable and meaningful activities even when motivation is gone. Do, then feel — not the reverse. Especially evidence-based for low-motivation depression. Track completion + mood before / after.
🛏️ Sleep Hygiene Routine + CBT-I if Insomnia
Same wake-time daily. No screens 1 hr before bed. Cool, dark, quiet bedroom. Bed for sleep + sex only. CBT-I (CBT for insomnia) is evidence-based and often more durable than sleep meds. Many CBT-I apps available.
☀️ Light-Therapy Box for SAD
10,000 lux light box, 30 minutes within 1 hour of waking, fall through spring. First-line for Seasonal Affective Disorder. ~$50–150 one-time cost. Pair with morning outdoor walk if possible.
🏃 Exercise Prescription
30+ minutes most days, aerobic + resistance. Effect size in mild-moderate depression comparable to SSRIs (multiple RCTs). Walking counts. Resistance training 2× weekly preserves function and helps mood. Do it even when you don't feel like it.
🧠 CBT Thought-Record Practice
The classic CBT homework: situation → automatic thought → emotion → evidence for / against → balanced thought → outcome. Short daily practice. Particularly effective for ruminative depression.
🧘 Mindfulness Routine (MBCT for Relapse Prevention)
5–20 minutes daily. Mindfulness-Based Cognitive Therapy (MBCT) has evidence specifically for relapse prevention in recurrent depression. Apps: Calm, Headspace, Insight Timer, UCLA Mindful (most have free tiers).
⚡ ECT Preparation
If your team has recommended ECT for severe / treatment-resistant / psychotic / urgently suicidal depression: pre-procedure workup, anesthesia consult, family transportation plan, expected schedule (3×/week for 6–12 sessions), realistic memory-effect framing, what to do between sessions.
💉 Esketamine (Spravato) Clinic Visit Prep
FDA-approved for treatment-resistant depression. Administered in-clinic; observation period after each dose. Pair with oral antidepressant. Plan transportation home (no driving the day of). REMS program, prior-auth typically required — copay programs available.
🤰 Postpartum-Specific Routine
EPDS screening at 6 weeks + 3 / 6 / 12 months. SSRIs (especially sertraline) are first-line; many compatible with breastfeeding. Postpartum Support International 1-800-944-4773. Postpartum psychosis (severe confusion, hallucinations, mania) is a life-threatening emergency — ED.
👨👩👧 Family Ambassador "Notice and Name" Drill
The loved one notices changes (sleep, withdrawal, hopelessness, irritability) and names them out loud — without diagnosing. ASK directly about suicidal thoughts when worried. Lethal-means safety in place. Accompany to appointments. The asking itself is the first treatment.
🧪 In a Depression Clinical Trial?
Protocol literacy, side-effect tracking, when to call the study coordinator vs your usual behavioral-health team. Trials currently enrolling in psilocybin-assisted therapy, novel rapid-acting antidepressants, neurosteroid agents (zuranolone for postpartum), TMS protocols, and digital-therapeutic platforms.
+ Add Your Institution's Module
Drop in your own — local NAMI affiliate, behavioral-health center onboarding, faith-community partnership, school-based screening program, EAP integration, anything.
🛡️Force Field Emergency Card
🛡️ Force Field Emergency Card FRIDGE · WALLET · EMT-READY
A one-page emergency record for any EMT, ER, new doctor, or transition visit. Print one for the fridge, one for your wallet. Updates anytime. This is the document you hand to a stranger when you can't speak for yourself.
🤝 My Care Team — call list for any clinician picking up my care
📘My Health Passport
📘 My Health Passport PATIENT-OWNED JOURNAL
This is your record — not your hospital's. Log every visit, capture every question for next time, and watch your own trends. Many of you get care at more than one hospital, on more than one record system. This Passport travels with you. Future versions will let you import data directly from your patient portals (the "Blue Button" vision).
🩺Working With a Prepared Patient
Your patient is going through a structured, evidence-based course. Here's how to get the most out of every visit, reduce ED crisis use, support sustained remission, support the family Ambassador, and partner well. Built on the AHRQ SHARE Approach, the IOM teach-back method, NIMH and APA Practice Guideline for Depression alignment, USPSTF recommendations on PHQ-9 universal screening, SAMHSA evidence-based behavioral health, NAMI peer-support evidence, and AFSP suicide-prevention framework. 988 Lifeline and Crisis Text Line are surfaced throughout — patients should know them cold.
The SHARE Approach — your 5-step playbook
Use these steps in any order. Cycle back. Use teach-back at every transition. Source: AHRQ Pub. No. 25-0005 (Oct 2024).
💬Teach-Back & Risk Communication
The two highest-yield, lowest-cost SDM techniques. Use both at every visit.
🔁 Teach-Back (1–2 min)
- "Just so I know I explained it well — what would you tell your partner about why we're starting sertraline? About the 4–6 week wait? About what to do if you miss a dose? About when to call 988 vs me?"
- Open-ended ("what" / "how"), not yes/no.
- If they get it wrong: "I must not have explained it well — let me try a different way." Then teach-back again.
- Use it for: 4–6 week wait for med effect; do not stop SSRI/SNRI cold — taper required; black-box-warning monitoring in young people first 4–6 weeks; bipolar-screen rationale; lethal-means safety; written safety plan + 988; when to call vs ED.
- Document teach-back in your note — it's a quality measure and a billable element of care.
🔢 Communicating Numbers
- Use absolute risk, not relative. "13 out of 100" beats "13%" beats "1 in 8" beats "low risk."
- Keep denominators & timeframes constant when comparing options.
- Show, don't tell: icon arrays, Wong-Baker FACES, written summary.
- For PHQ-9 numbers: give the action threshold, not just the value. "Your PHQ-9 was 17 four weeks ago and is 12 today — that's a clinically meaningful response, but we still want to get below 5 (remission). Let's keep this dose another 4 weeks and reassess."
⚠️Depression-Specific Clinical Guardrails
Screening & Diagnostic Workup
- Universal PHQ-9 screening (USPSTF) for adults in primary care, including pregnant and postpartum people. PHQ-2 as triage; full PHQ-9 if positive. EPDS for perinatal.
- Item 9 (suicidal ideation): any positive answer triggers same-visit safety conversation regardless of total score. Document plan, intent, means, access.
- Always ask about manic episodes BEFORE starting an antidepressant — antidepressants alone in unrecognized bipolar can trigger mania or rapid cycling. Use MDQ or simple inquiry: racing thoughts, decreased sleep need, grandiosity, risky behavior, periods of unusual energy / irritability.
- Rule out medical mimics: TSH (hypothyroidism), CBC (anemia), B12 / folate / vitamin D, metabolic panel. Consider sleep apnea screen (STOP-BANG) in fatigue-prominent depression.
- Substance use screening: AUDIT (alcohol), DAST-10 (drugs). Comorbid SUD changes the plan; refer to addiction medicine.
- Trauma screening: relevant history (abuse, combat, accident) shifts approach toward trauma-informed care; consider PTSD-specific eval if symptoms fit.
- Cognitive screening in older adults (MoCA / MMSE) — depression and dementia overlap and can mask each other.
Evidence-Based Treatment
- Therapy first-line for mild-moderate: CBT, IPT, behavioral activation, problem-solving therapy, MBCT. 12–20 sessions typical; effect persists after treatment ends.
- Medications first-line for moderate-severe: SSRIs (sertraline, escitalopram, fluoxetine, citalopram with QTc caution >40 mg, paroxetine has more withdrawal). Generally well-tolerated; 4–6 weeks to full effect; common side effects GI / sexual / sleep.
- SNRIs: duloxetine, venlafaxine — useful with comorbid pain; monitor BP especially at higher doses.
- Atypicals: bupropion (no sexual side effects, activating, lowers seizure threshold; avoid in eating disorders); mirtazapine (sedating, weight gain, useful for sleep + appetite).
- Combination (med + therapy) wins for moderate-severe.
- Withdrawal is real — taper, do not stop cold; SSRI/SNRI discontinuation syndrome is flu-like, dizziness, electric-shock sensations.
- Black-box warning: increased suicidal thoughts in young people in first 4–6 weeks of SSRI start. The risk of UNTREATED depression is far greater. Close monitoring is the answer, not avoiding treatment.
- Treatment-Resistant Depression: failure of ≥2 adequate trials → consider esketamine (Spravato), ECT (highly effective for severe, psychotic, urgently suicidal), TMS (non-invasive). Destigmatize ECT.
- Postpartum: SSRIs (esp. sertraline) first-line; many compatible with breastfeeding. Brexanolone / zuranolone are newer perinatal-specific options.
- Bipolar Depression: mood stabilizers (lithium, lamotrigine, quetiapine) ± atypicals; antidepressants alone risk inducing mania.
Suicide Risk Assessment & Crisis Management
- Ask directly about suicidal ideation at every visit — asking does NOT plant the idea (landmark evidence). Use Columbia Suicide Severity Rating Scale (C-SSRS) or similar structured tool. Document.
- Lethal-means counseling is the single most effective suicide-prevention intervention. Firearms: safe storage / off-site at peak risk. Medications: lockboxes, days-of-supply only at home.
- Written safety plan (Stanley-Brown style): warning signs, internal coping skills, distractions, supportive people, professional contacts (988, Crisis Text Line, behavioral-health team), lethal-means safety. Update at every visit.
- 988 Suicide & Crisis Lifeline (call or text 988); Crisis Text Line (text HOME to 741741); Veterans Crisis Line (988 then press 1). Know them cold; share with every patient.
- Hospitalization for active suicidality with plan and intent and access; loss of capacity to maintain safety; severe psychotic depression. Voluntary preferred; involuntary per state law when needed.
- Postpartum psychosis = psychiatric emergency (risk of infanticide + suicide); ED admission.
- Serotonin syndrome with multiple serotonergic agents = ED (fever, agitation, tremor, rigidity, autonomic instability).
Monitoring & Follow-Up
- PHQ-9 weekly while in active treatment; q3 months in remission. Trend matters more than single score.
- Re-evaluate at 4–6 weeks after dose initiation/escalation. If <25% reduction in PHQ-9, increase dose or switch / augment.
- Continue treatment 6–9 months after remission for first episode; indefinitely for recurrent or severe.
- Relapse prevention: written plan, MBCT for recurrent depression, continued therapy or maintenance med.
- Collaborative-care model (PCP + therapist + RN care manager + psychiatrist consultant) has ~3× better outcomes than usual care; advocate for it.
- Cultural competence: somatic presentations in many communities, different help-seeking norms, language-matched care matters; The Trevor Project for LGBTQ+ youth.
- Mental Health Parity (MHPAEA): enforce coverage; file complaints if denied.
🌍Cultural Competence & Trust
Depression carries deep stigma that delays care and worsens outcomes — and the patterns differ by community. Men often present with irritability, anger, or substance use rather than sadness; help-seeking is lower; suicide rates are 3–4× higher than women's. African American communities often present with somatic complaints; faith-community partnerships matter; AA-led therapists help. Latino communities use cultural idioms ("ataque de nervios"); bilingual / bicultural therapists matter. AAPI communities have the lowest mental-health utilization in the U.S. Indigenous communities carry historical trauma; community-based, traditional-healing-integrated care works. LGBTQ+ youth have ~4× the suicide-attempt risk of cisgender heterosexual peers; family acceptance is the single biggest protective factor. Older adults often present with memory complaints, somatic symptoms, withdrawal; older men have very high suicide rates. Repair starts in your office.
- Use universal PHQ-9 screening (USPSTF) as the standard. Don't wait for the patient to "look depressed." Add EPDS in perinatal.
- Plain framing: depression is a medical condition, not a character flaw. Treatment effectiveness ranks among the best in medicine.
- Match the messenger when possible: cultural / linguistic / faith-aligned therapist; AA-led, Latino, AAPI, Indigenous, LGBTQ+-affirming clinicians.
- Use qualified medical interpreters — never family, never minor children except in true emergencies. Mental-health conversations must be done in the patient's primary language.
- Invite the family Ambassador in with patient consent. The "Notice and Name" role is real medicine. Asking about suicide does not plant the idea — landmark evidence on this.
- Lethal-means counseling without judgment, regardless of community. Especially important in rural areas, veterans, older men.
- Name the bias. "Depression is a medical condition. Getting treated is strong, not weak. Stigma is real — tell me if anything feels off about how the system or I am treating you."
- The Trevor Project 1-866-488-7386 / text START to 678678 for LGBTQ+ youth. Postpartum Support International 1-800-944-4773. NAMI HelpLine 1-800-950-6264. SAMHSA 1-800-662-HELP.
🏥Customize for Your Institution
Clone this course and replace the highlighted blocks with your own information. Each editable field below is a placeholder — change it once and it propagates through the patient view.
📞 What Should Replace the When-to-Call Block
- 988 Suicide & Crisis Lifeline (call or text) · 741741 Crisis Text Line (text HOME) · 988 then press 1 Veterans
- 24/7 behavioral-health on-call number / Mobile Crisis team
- Outpatient psychiatry + therapy clinic hours & address
- Pharmacy line (SSRIs / SNRIs / atypicals / esketamine REMS)
- EAP entry point (typically 3–8 free sessions, confidential)
- NAMI HelpLine 1-800-950-6264 + SAMHSA 1-800-662-HELP
- Trevor Project 1-866-488-7386 / text START to 678678 (LGBTQ+ youth)
- Postpartum Support International 1-800-944-4773
- Patient portal login URL with Ambassador proxy
👤 Who Is Your Behavioral-Health Care Navigator?
- Name, role, photo, scheduling link.
- What teach-back / check-ins they own (weekly PHQ-9, written safety plan + 988, lethal-means safety, CBT/IPT homework, behavioral activation tracker, sleep hygiene, family Ambassador "Notice and Name" partnership).
- How patients and Ambassadors reach them between visits.
- How they handle prior-auth navigation (esketamine, TMS, brand-name antidepressants), copay help, MHPAEA parity-complaint filing if denied, and EAP referral.
📚 Add Your Own Modules
- Your clinical trial protocols (psilocybin-assisted therapy, novel rapid-acting antidepressants, neurosteroid agents like zuranolone for postpartum, TMS protocols, digital-therapeutic platforms).
- Collaborative-care model implementation (PCP + therapist + RN care manager + psychiatrist consultant — ~3× better outcomes than usual care).
- Insurance & financial-aid pathways (especially MHPAEA parity enforcement, sliding-scale via training clinics / CMHC / FQHC / Open Path Collective, EAP integration).
- Local peer support partners (NAMI affiliate · AFSP "Out of the Darkness" walks · DBSA support groups · Trevor Project · Postpartum Support International · faith-community partnerships).
🎨 Re-skin in 2 Lines of CSS
--inst-primary: your brand color- Replace the FFH × NAMI × [Your Institution] cobrand in the hero
- Drop in your logo PNG (white version) — same 48px height as FFH logo
📚 Evidence Base — what this course is built on
- AHRQ SHARE Approach — 5-step shared decision making framework. AHRQ Pub. 25-0005, Oct 2024. ahrq.gov/sdm
- AHRQ Health Literacy Universal Precautions Toolkit (3rd ed.) — teach-back, plain language, accessible materials. AHRQ Pub. 23-0075, March 2024.
- NIMH · Depression — comprehensive patient and clinician summaries.
- NAMI · National Alliance on Mental Illness — peer-mentor program (Peer-to-Peer + Family-to-Family), HelpLine 1-800-950-6264, advocacy.
- AFSP · American Foundation for Suicide Prevention — "Talk Saves Lives" education, "Out of the Darkness" walks, suicide-prevention research and advocacy.
- SAMHSA · Substance Abuse and Mental Health Services Administration — treatment locator 1-800-662-HELP (4357), evidence-based behavioral health.
- USPSTF Depression Screening (PHQ-9) — universal screening recommendation in primary care for adults including pregnant and postpartum people.
- Lancet Commission on Depression (2022) — global epidemiology, burden of disease, equity framework.
- ADAA · Anxiety and Depression Association of America — evidence-based education and support; sister organization for the Anxiety course.
- 988 Suicide & Crisis Lifeline — call or text 988, free, confidential, 24/7. Crisis Text Line: text HOME to 741741. Veterans Crisis Line: 988 then press 1.
- The Trevor Project — 1-866-488-7386 / text START to 678678 — for LGBTQ+ youth in crisis.
- Postpartum Support International — 1-800-944-4773 — for perinatal mood and anxiety disorders.
- STAR*D Study (NIMH) — landmark sequencing trial; ~60–70% respond to first-line, ~80% with sequencing through second/third treatments.
- APA Practice Guideline for the Treatment of Patients With Major Depressive Disorder — evidence-based pharmacotherapy and psychotherapy guidance.
- Stanley-Brown Safety Plan — evidence-based written safety-planning intervention adopted by 988, AFSP, and the VA.
- SMILES Trial (Jacka et al., 2017) — Mediterranean-style diet improves depression outcomes; foundational for the lifestyle-as-medicine framing.
- FFH Cluster Courses (HTN / T2D / CHF / CAD / post-MI / post-stroke / Alzheimer's / MS / brain tumor / cirrhosis / CKD) — Module 7 in each course mentions depression / anxiety as common comorbidities; the canonical cluster module (md5 7587a559b24ca8b9bab40b1756475d84) is CROSS-REFERENCED from this Depression course's Module 7, NOT embedded or modified.
- FFH Prepared Patient · Anxiety course — sister Sprint 6 course; together Depression + Anxiety form the mental-health cohort and close the bidirectional mood-medical loop for the entire FFH library.
Course content is educational and not a substitute for medical advice from your own clinicians. Institutions cloning this course are responsible for accuracy of all customized blocks.