Depression Management

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Core management
  • Exclude general medical cause
  • For mild/moderate use psychosocial treatments
  • For moderate/severe consider addition of antidepressant medication
  • Psychoeducate patient and guardians
  • Manage any side-effects
Red Flags
  • If there is a high risk of suicide or self-neglect (e.g. not drinking and eating enough) or there are psychotic features (delusions, hallucinations, stupor) admit to hospital. May need to be detained using the Mental Health Act.
  • If the person is experiencing domestic violence, encourage to access local abuse support services and the police if needed.

Physical Exams and Investigations

  • Always do a physical examination to look for reversible cause e.g. hypothyroidism, anaemia. Refer for treatment of any physical illnesses.
  • Assess for signs of dehydration and/or malnutrition
  • FBC, U&E, glucose + VDRL, consider TFTs, HIV test, urine drug screen if appropriate.

Treatment

The aim of treatment is to completely resolve symptoms so to relieve distress and allow the person to return to their previous activities.

Involving family in the management plan is important and usually helpful. However, be aware that relationship problems and abuse are common stressors that can cause depression.

Psychosocial

If mild-moderate depression (still managing to undertake most of daily activities):

  • Supportive counselling and problem solving (listen to and try to understand their problems, help them to think about possible solutions, encourage enjoyable activities) See section on psychosocial interventions.
  • Consider referral to local supportive groups (e.g. church, women’s groups, MeHUCA)
  • Manage any alcohol or drug use – see section
  • If not improving, consider referral for specialist psychotherapy

Medication

For moderate to severe depression (or milder depression persisting despite counselling). Explain that antidepressants take 1-4 weeks before improvements are noticed.

1st line:

  • Fluoxetine 20mg od
  • If no/partial response, increase to 40mg after 3 - 4 weeks to max of 60mg (rarely needed)
  • Monitor for side effects (agitation, initial increase in anxiety, GI upset, insomnia)

2nd line:

If not improved on Fluoxetine after 4-6 weeks or not tolerating:

  • Switch to Amitriptyline 75mg nocte – start at 25mg and increase by 25mg every 3 days until dose is 75mg – helps with tolerability.
  • Increase every 2 weeks by further 25mg if symptoms persist up to max. of 200mg nocte
  • Monitor for side effects (sedation, hypotension, dry mouth, constipation, sexual dysfunction)

NOTE: If patient is suicidal, give Amitriptyline to the carer to keep safe – Amitriptyline can be fatal in overdose due to cardiac effects.

If patient is elderly or physically frail (e.g. HIV) reduce the starting dose to Amitriptyline 25mg nocte and increase the dose slowly.

If psychotic symptoms present, add an antipsychotic and consider referral/admission

Chlorpromazine 50-150mg nocte or Haloperidol 1.25-2.5mg nocte

Increase dose every 2 weeks until psychotic symptoms have resolved

Referral/Admission

  • Ongoing or worsening symptoms
  • Depression with psychotic symptoms
  • Persistent or increasing suicidal ideation
  • Evidence of dehydration or malnutrition

Follow-Up

  • Review the patient once a week until improving, thereafter every 2-4 weeks.
  • Assess risk for committing suicide and side-effects at every review
  • Continue medication for 6 months from complete resolution of symptoms (first episode) or 2 years (recurrent depression)
  • Stop antidepressants gradually over 4-8 weeks, longer if necessary.