Depression

Clinical Description

• Presence of low mood, with decreased energy and anhedonia, most days for at least 2 weeks
• If it is moderate to severe there is impairment of the usual occupational and functional activities such as going to work, housework and self-care
• Suicidal ideation should be asked about at every assessment

Signs and Symptoms

• Low mood or irritability
• Reduced energy
• Lack of enjoyment of previously pleasurable activities
• Poor or excessive sleep
• Reduced appetite and weight loss (or increased appetite and weight gain)
• Poor attention and concentration
• Feelings of guilt and worthlessness
• Suicidal ideation
• Looks sad
• Poor eye contact
• Reduced speech at low volume
• Evidence of weight loss and poor self-care
• Possible agitation
• If severe psychotic symptoms (delusions and hallucinations), catatonic symptoms e.g., mutism

Investigations

• Some physical illnesses can present with depressive symptoms e.g., anaemia, hypothyroidism, HIV, syphilis so these must be excluded
• Full physical examination including vital signs
• FBC, U&E, glucose
• If evidence of hypothyroidism on examination
• (Weight gain, dry skin, goitre) check TFTs if possible
• VDRL
• PITC
• Urine drug screen if available

Treatment

• The aim of management is to completely resolve symptoms, if possible, to allow the person to return to their previous activities and occupation
• If the presentation is a first episode, treat for 6 months after remission. In second episode treat for up to 2 years. Subsequent episodes require lifelong treatment.

Primary treatment

• If mild to moderate depression
• first line treatment should be supportive counselling, problem solving skills and physical exercise
• Consider referring to local supportive groups e.g church, womens groups
• If moderate to severe, or if mild depression persists despite counselling commence anti- depressant treatment
• Give Fluoxetine 20mg daily
• Increase after 3-4 weeks by 20mg up to a maximum of 60mg daily depending on response and side effects)
• Monitor for side effects (agitation, increase in anxiety initially, insomnia, GI upset, sexual side effects)
• If fluoxetine is not available give Amitriptyline 50-75mg nocte
• Increase after 2 weeks by 25mg if symptoms persist up to a maximum of 150mg
• Monitor for side effects (sedation, hypotension, dry mouth, constipation, sexual dysfunction)
• Avoid the use of amitriptyline for the management of depression in patients on ARV’s and/or isoniazid. Where available, use sertraline 50mg daily. If no improvement after 4 weeks refer.
• Avoid amitriptyline in elderly individuals. Use fluoxetine.
• Explain that antidepressants have delayed onset of action and it may take 1- 2 weeks before improvements are noted
• Do not prescribe amitriptyline if suicidal ideation is present. If fluoxetine is unavailable, amitriptyline should be kept and administered by a guardian

Note that Amitriptyline can be fatal in overdose due to cardiac effects). If no guardian, admit the patient until suicidal ideation is resolved.

• If psychotic symptoms (hallucinations or delusions) present, add an anti- psychotic and consider referral

Primary treatment

Caution should be used when prescribing medication to pregnant and breast- feeding women.

• If mild to moderate depression, treat with supportive counseling.
• If severe depression, antidepressants should be considered. Untreated depression can lead to adverse pregnancy outcomes
• Where possible delay initiation of antidepressants to second trimester and use psychotherapy unless if benefits outweigh risks. The risks of treatment should always be discussed with the patient and the management should be patient informed
• If medication is required:
• Where available, give sertraline 50mg daily as it is safe for use in pregnancy and lactation
• Give Amitriptyline: start at 25- 50mg nocte and increase slowly. Avoid during first trimester of pregnancy. Monitor the baby for evidence of sedation as small amounts can be found in the breast milk.
• Give Fluoxetine 20 mg daily: May be used in pregnancy. Avoid in breastfeeding mothers.
• Otherwise follow Depression Treatment Guidelines as above

Red Flags

For referral

• Ongoing or worsening symptoms despite adequate anti-depressant treatment for 4 weeks
• Depression with psychotic symptoms
• Persistent or increasing suicidal ideation or if the person has developed a suicide plan
• Evidence of self-neglect, dehydration or malnutrition

For admission

Evidence that the patient is a risk to themselves (self-harm/ neglect/ vulnerable to exploitation) or a risk to others (agitation/ aggression)

• Severe depression with psychotic symptoms and evidence of psychomotor retardation, this is an emergency and should be referred for admission for consideration of Electro Convulsive Therapy (ECT)
• If patient has active plans of suicide or a recent suicidal attempt.
• Thoughts of harming others.
• Evidence of self-neglect including not eating and drinking properly which may require intravenous fluids

Follow-up

• At each review, ask about symptoms, suicidal ideation, and side effects from medication.
• Monitor for emergence of manic symptoms
• as some people can develop manic symptoms when treated with anti-depressants.
• Give supportive counselling to patient (see mild -moderate depression above).
• Advise to increase physical activity gradually once improved and to return to usual activities when possible, including work if employed.
• When considering stopping medication, discuss carefully with the patient and guardian and start to reduce slowly over 4-8 weeks. Advise about symptoms that would indicate relapse such as difficulty sleeping, low mood, reduced energy, increase worries and inform to return to the clinic promptly. Continue to monitor until medication free for 1-2 months before discharging
• Depression occurring during pregnancy or within six months of childbirth
• Assess risk of: self-harm, harm from mother to baby and neglect of the baby.
• If any concerns admit or refer for review.