Gus Alva, MD

Start low and go slow collides with therapeutic urgency more often than guidelines admit. Dr. DeBattista walks through the hepatic, renal, and cytochrome considerations that force a prescriber's hand.

The weeks spent waiting for an antidepressant to work are a window for dropout and risk. The panel debates who earns a faster-acting option up front and what monitoring that choice requires.

A significant improvement on a rating scale can still leave a patient unable to function. Dr. DeBattista explains how he defines meaningful improvement and when non-response should change the plan.

One approval took decades and a stack of complete response letters. Dr. Clayton reviews where these two agents fit, what their trials showed, and why patient preference should drive the choice.

An oral glutamatergic option without the logistics of ketamine. Dr. Shirikjian walks through the trial program, the week-one separation, and the mechanism she had to unlearn to understand.

Older antidepressants did not get less effective, only less convenient. Dr. Clayton explains where tricyclics and MAOIs still belong, and when combining psychotherapy with medication outperforms either alone.

Most depression in this country is never treated by a psychiatrist. The panel maps which parts of the journey primary care can own, where handoffs break down, and what safety demands first.

The imaging evidence is associational, not causal. The panel weighs whether that is reason enough for a skeptical colleague to treat depression earlier, and how anxiety complicates the picture.

Fatigue and poor sleep send patients to primary care, but a CBC and a thyroid panel will not find depression. The panel examines what actually separates major depression from its mimics.

Depression rarely arrives named. The panel opens on the presentations that mask it, the risk factors worth flagging in primary care, and the lag between first symptom and adequate treatment.