The Lingering 'Blah': Residual Symptoms and Sleep as an Early Warning Sign

In "The Lingering 'Blah': Residual Symptoms and Sleep as an Early Warning Sign," our experts turn to the residual symptoms that linger even after a patient starts to respond.

Dr. Harding says the most common lingering complaint she hears is a vague feeling of "blah." She draws a parallel to patients who seek controlled substances in the emergency room, arguing that what people chase is relief, not addiction itself, and that patients stay on medications that deliver noticeable, fast benefit. Psychiatric patients, she notes, don't weigh their medication decisions the way an oncology patient weighs a modest chance at cancer remission, because relief has to feel tangible and immediate to sustain adherence. Stimulants keep patients engaged because their onset is quick, while antidepressant benefit is slower, and she believes the field has not done enough to set patient expectations around that timeline.

She describes a recent consult in which a patient on escitalopram for two decades blamed the drug for a twenty-pound weight gain, tapered off, and then watched her depressive symptoms return, illustrating how attribution confusion around residual symptoms can lead to premature discontinuation. In her own middle-aged patient population, spanning roughly forty-five to ninety years old, anhedonia and sleep disturbance are the residual symptoms she hears about most, though aging-related complaints can complicate the picture. Despite that nuance, she and her colleagues target low mood and anhedonia aggressively as primary goals.

Dr. Citrome agrees anhedonia is central to MDD but notes patients often lack insight into it, whereas sleep is something patients can report with real accuracy because they view it neutrally. He asks about sleep at every visit, reinforcing improvement and watching for early difficulty falling or staying asleep as a warning sign. That check-in also opens the door to his signature screening question about past periods of reduced need for sleep, which can flag bipolar depression and change which medications are appropriate, since standard antidepressants can worsen it or simply fail outright.

Next, in "Reading Body Language in MDD: A Story That Changed Practice," Erin Crown, MHS, PA-C, CAQ-Psychiatry shares how she reads what patients don't say, including a story that reshaped how she practices.