Case Presentation:

 A 29-year old woman who is three months postpartum with her fifth child comes to the clinic to talk about her worsening depression.  You have cared for this woman over the years, most recently for her prenatal care and delivery. During that time she took herself off all psych/mental health drugs which included Zoloft 100mg and buspar 15mg TID for anxiety.  She is a long term pot smoker at least 2 x a day and smoked pot during her pregnancy for nausea. You counseled her several time to stop. She had a stable pregnancy and did not have any symptoms of depression during the pregnancy.  She is married to the father of all of her children and has a good relationship with him. Lately she has been more withdrawn at home and wants to just stay in her room with the baby all day. In a bipolar assessment of her symptoms (MDQ) screening questionnaire, she scored very high on the bipolar scale.  You know that her previous meds have not helped her symptoms and she goes though time when she cannot sleep for weeks at a time. 

What else might you want to know from this patient? 

The first thing I would ask this patient is how long her symptoms have been present. The key indicator is 2 weeks or more with persistent symptoms for the diagnosis of major depression. I would want to know if she has any suicidal ideation or thoughts about death, to assess her safety and see if she is at risk for suicide. If she is, then I would follow the institutes protocol for baker acting this patient. Suicide risk can be initially assessed in the PHQ-9 screening questionnaire that the patients can fill out at the beginning or during the visit. The Ask Suicide-Screening Questions (ASQ) tool is a brief validated tool for use among both youth and adults. The Joint Commission approves the use of the ASQ for all ages (Ask suicide screening, 2021).. Additional materials to help with suicide risk screening implementation are available in The Ask Suicide-Screening Questions (ASQ) Toolkit, a free resource for use in medical settings (emergency department, inpatient medical/surgical units, outpatient clinics/primary care) that can help providers successfully identify individuals at risk for suicide (Ask suicide screening, 2021). The ASQ toolkit consists of youth and adult versions as some of the materials take into account developmental considerations (Ask suicide screening, 2021).. I would ask the patient about her use of marijuana or other illicit drugs and the frequency of her usage. In addition, I would also assess for alcohol use/abuse, which can worsen depression.