SIG E CAPS

Memory hook for the eight accompanying symptoms of a major depressive episode (8 of the 9 DSM-5 symptoms; the ninth, depressed mood, is the anchor and is not in the letters).

S — Sleep changes

Insomnia (classically early-morning awakening) or hypersomnia

Sleep disturbance is one of the most common depressive symptoms and can go in either direction. Insomnia, especially early-morning awakening (waking 2-3 hours early unable to return to sleep), is classic; hypersomnia occurs more in younger patients and atypical depression. Must represent a change from baseline.

Physiology. Dysregulation of monoamine systems and the HPA stress axis disrupts circadian rhythm and sleep architecture (less slow-wave sleep, early REM onset).

Safety. New/worsening insomnia with agitation can raise suicide risk in the early treatment window; monitor when antidepressants are newly started.

I — Interest loss (anhedonia)

Loss of interest or pleasure in nearly all activities

Anhedonia is loss of interest/pleasure in nearly all activities most of the day, nearly every day. It is one of two core symptoms (with depressed mood) — at least one must be present for diagnosis. May appear as social withdrawal, loss of sexual interest, or indifference to hobbies.

Physiology. Reduced responsiveness of dopamine-mediated reward circuitry (ventral striatum, nucleus accumbens), so previously rewarding activities no longer feel rewarding.

Safety. Profound anhedonia with hopelessness drives suicidal thinking ('nothing will ever feel good again'); do not mistake flatness for being okay.

G — Guilt / worthlessness

Excessive or inappropriate guilt; feelings of worthlessness

Feelings of worthlessness or excessive/inappropriate guilt nearly every day, disproportionate to actual events. Ranges from self-critical rumination to delusional guilt in psychotic depression.

Physiology. Negative cognitive bias (negative views of self, world, future) with altered ventromedial prefrontal and overactive self-referential (default mode) network activity.

Safety. Guilt and worthlessness are strongly linked to suicidality; take 'they'd be better off without me' statements seriously and ask about self-harm.

E — Energy loss (fatigue)

Fatigue or loss of energy nearly every day

Fatigue/loss of energy nearly every day, present without physical exertion and not explained by another medical condition. Often described as heavy or 'leaden' (leaden paralysis in atypical depression).

Physiology. Disrupted arousal/motivation systems (monoamines, HPA axis) lower baseline energy; sleep disturbance compounds it.

Safety. Severe retardation plus fatigue can lead to poor intake, dehydration, and self-neglect; monitor nutrition and hydration.

C — Concentration difficulty

Diminished ability to think, concentrate, or make decisions

Diminished ability to think, concentrate, or decide nearly every day ('brain fog', re-reading the same page, indecisiveness). In older adults it can mimic dementia ('pseudodementia').

Physiology. Reduced prefrontal cortex activity (attention, working memory, executive function); rumination consumes cognitive capacity.

Safety. Impaired concentration can affect understanding of instructions, medication management, and driving safety.

A — Appetite / weight changes

Significant weight loss or gain; appetite decrease or increase

Significant weight change (>5% body weight in a month) or appetite change, in either direction. Decreased appetite/weight loss is classic in melancholic depression; increased appetite/weight gain with hypersomnia is more typical of atypical depression.

Physiology. Hypothalamic hunger regulation is disrupted by the same monoamine and HPA-axis systems affected in depression.

Safety. Profound weight change can cause electrolyte imbalance, malnutrition, or metabolic effects; monitor nutrition and hydration.

P — Psychomotor changes

Psychomotor agitation (restlessness) or retardation (slowing)

Observable psychomotor agitation (pacing, hand-wringing) or retardation (slowed speech/movement, long pauses), nearly every day. Retardation may be mistaken for 'calm' but is a sign of severe depression.

Physiology. Dysregulation of motor pathways and basal ganglia; severe retardation can be a feature of melancholic or catatonic depression.

Safety. Severe agitation raises suicide risk and fall risk; severe retardation can progress to catatonia or stupor — both need urgent psychiatric evaluation.

S — Suicidal ideation

Recurrent thoughts of death, suicidal ideation, or attempts

Recurrent thoughts of death, suicidal ideation (with or without a plan), or a suicide attempt. The most dangerous symptom of depression and a psychiatric emergency when there is intent, a plan, or access to means.

Physiology. Cognitive constriction (narrowed thinking) and hopelessness distort the future into 'nothing will get better'; hopelessness more than sadness predicts suicidal behavior.

Safety. If ideation with plan/intent is present, initiate 1:1 observation, remove means, and escalate immediately. A no-suicide contract is not a substitute for safety assessment.

Memory aids

• S = Sleep changes
• I = Interest loss (anhedonia)
• G = Guilt / worthlessness
• E = Energy loss (fatigue)
• C = Concentration difficulty
• A = Appetite / weight changes
• P = Psychomotor changes
• S = Suicidal ideation

Quick review

• S = Sleep changes — Insomnia (classically early-morning awakening) or hypersomnia
• I = Interest loss (anhedonia) — Loss of interest or pleasure in nearly all activities
• G = Guilt / worthlessness — Excessive or inappropriate guilt; feelings of worthlessness
• E = Energy loss (fatigue) — Fatigue or loss of energy nearly every day
• C = Concentration difficulty — Diminished ability to think, concentrate, or make decisions
• A = Appetite / weight changes — Significant weight loss or gain; appetite decrease or increase
• P = Psychomotor changes — Psychomotor agitation (restlessness) or retardation (slowing)
• S = Suicidal ideation — Recurrent thoughts of death, suicidal ideation, or attempts