DEPRESSION

A common disorder characterised by low mood, loss of interest and enjoyment and reduced energy leading to
diminished activity and in severe forms, difficult day-to-day functioning.

Causes

  • Biological, genetic, and environmental factors

Clinical features

For at least two weeks, the person had at least two of the symptoms below:

  • Low mood (most of the day, almost every day)
  • Loss of interest or pleasure in activities that are normally pleasurable
  • Associated lack of energy, body weakness or easily fatigued

During the 2 weeks, the person also has some of the symptoms below:

  • Difficulty in concentrating, reduced attention
  • Reduced self esteem and self confidence
  • Poor sleep, poor appetite, reduced libido
  • Bleak and pessimistic view of the future
  • Feeling of guilt and unworthiness
  • Multiple body pains or other medically unexplained somatic symptoms
  • Ideas or acts of self harm or suicide (occurs in up to 65% of patients)
  • Children and adolescents usually present with irritability, school phobia, truancy, poor academic performance,
    alcohol and drug abuse

Differential diagnosis

  • Thyroid dysfunction (hypothyroidism)
  • Adrenal dysfunction (Addison’s disease)
  • Parkinson’s disease, stroke, dementia
  • Anxiety disorder

Investigations

  • Medical, social and personal history
  • Check for bereavment or other major personal loss
  • Find out if person has had an episode of mania in the past: if so consider treatment for bipolar disorder and consult a specialist
  • Find out if they have psychotic features e.g. hallucinations (refer to section on Psychosis)
  • Assess for co-occurring health conditions (e.g. HIV/AIDS), substance or alcohol abuse
  • Assess risk of self harm/suicide

Management

First line

  • Psychological support may be adequate in mild cases:
    • Psychoeducation (counselling of patient and family)
    • Addressing current stressors (abuse, neglect…)
    • Re activating social networks
    • Structured physical activities
    • Regular follow up
  • Manage concurrent physical medical problems
  • Address co-existing mental problems e.g. substance abuse
  • If available, consider psychotherapy (cognitive behavioural therapy, interpersonal
    psychotherapy, behavioural activation etc)

If bereavement or another major personal loss

  • Counselling and support
  • Do not consider drugs or psychotherapy as first line

If not responding to all above

  • Consider antidepressant
    • DO NOT use in children <12 years
    • Adolescents: only under specialist supervision
  • Fluoxetine 20 mg once daily in the morning
    • Start with 10 mg in elderly
    • If not better after 4-6 weeks, increase to 40 mg ffOr Amitriptyline 50 mg at bedtime
    • Increase by 25 mg every week aiming at 100-150 mg in divided doses or single bedtime dose by 4-6
      weeks of treatment
    • Useful in case of associated anxiety
    • Avoid in adolescents, elderly, heart diseases, suicide risks

If patient responding to medication

  • Continue for at least 9-12 months
  • Consider stopping if patient has been without depressive symptoms and able to carry out
    normal activities for at least 9 months

    • Counsel the patient about withdrawal symptoms (dizziness, tingling, anxiety, irritability, nausea,
      headache, sleep problems)
    • Counsel the patient about possibility of relapse and when to come back
    • Reduce slowly over at least 4 weeks even slower if withdrawal symptoms are significant
    • Monitor periodically for re-emergence of symptoms

In case of pregnant woman, child, adolescent, patients not responding to treatment with
antidepressant, psychotic features, history of mania

  • Refer for specialist management
Caution
  • SSRI in bipolar depression can trigger a manic episode. If history of mania refer to specialist

Prevention

  • Stress management skills
  • Promotion of useful social support networks