Depression

Last updated: July 2022

Depression is characterised by a set of symptoms that have been present at least two weeks and represent a change from previous functioning.

The standard criteria for diagnosis of major depressive disorder are:

• Pervasive sadness and/or a lack of interest or pleasure in activities normally found pleasurable and
• At least four of the following signs:
  • Significant change in appetite or weight
  • Insomnia, especially early waking (or, more rarely, hypersomnia)
  • Psychomotor agitation or retardation
  • Significant fatigue, making it difficult to carry out daily tasks
  • Diminished ability to make decisions or concentrate
  • Feelings of guilt or worthlessness, loss of self-confidence or self-esteem
  • Feelings of despair
  • Thoughts of death, suicidal ideation or attempt

The features of depression can vary according to the patient’s culture a Citation a. Hence the importance of working with an “informant” (in the anthropological sense of the word) when dealing with unfamiliar cultural contexts. . For example, the depressed patient may express multiple somatic complaints rather than psychological distress. Depression may also manifest itself as an acute psychotic disorder in a given cultural context.

Management

When faced with symptoms of depression, consider an underlying organic cause (e.g. hypothyroidism or Parkinson’s disease) or adverse effects from medical treatment (corticosteroids, cycloserine, efavirenz, mefloquine, etc.). Look for a triggering event (e.g. sexual violence, recent childbirth and post-partum depression).

Depressive disorders are the most common mental disorders in patients with severe chronic infectious diseases such as HIV infection or tuberculosis. These disorders should not be neglected, especially as they have a negative impact on adherence to treatment.

Symptoms of depression are common after a major loss (bereavement, forced displacement, etc.). They gradually subside, in most cases, with social support. Psychological support may be useful.

Pharmacological treatment should always be offered, along with counseling, to patients with severe depression (Patient Health Questionnaire-9 (PHQ-9) score > 19; severe functional impairment, psychotic symptoms, and/or suicidal risk). 

In patients with moderately severe depression (PHQ-9 score 15-19), pharmacological treatment should be considered if there is no improvement after 3 counselling sessions, or from the outset if patients express a personal preference for it.

Before prescribing, make sure that 9-month treatment and follow-up (psychological support, adherence and response) are possible.

Preferably use a serotonin reuptake inhibitor (SRI), particularly in older patients. Preferably use fluoxetine, except during pregnancy when sertraline is preferred.
fluoxetine PO: 20 mg on alternate days for one week, then once daily for 3 weeks, then increase the dose if necessary (max. 40 mg daily); use with caution in patients with severe anxiety disorders or who are immobilised (e.g. wounded)
or
paroxetine PO: 10 mg once daily for 3 days, then 20 mg once daily for 3 weeks, then increase the dose if necessary (max. 40 mg daily), especially if the depression is accompanied by severe anxiety
or
sertraline PO: 25 mg once daily for 3 days, then 50 mg once daily for 3 weeks, then increase the dose if necessary (max. 100 mg daily)

Assess tolerance and response every week for 4 weeks. If the response is inadequate after 4 weeks at optimal dose or if the SRI is poorly tolerated, replace with another SRI (there is no need for a medication-free interval between the two).
If SRIs are not available, amitriptyline PO may be used as an alternative: start with 25 mg once daily at bedtime and gradually increase over 8 to 10 days to 75 mg once daily (max. 150 mg daily). The therapeutic dose is close to the lethal dose; in older patients, reduce the dose by half.

There is a delay of 2 to 3 weeks before the antidepressant effect of SRIs occurs, at least 4 weeks for amitriptyline. During this period, anxiety may be exacerbated and the risk of suicide may increase, especially with fluoxetine. Hydroxyzine PO (25 to 50 mg 2 times daily, max 100 mg daily) or promethazine PO (25 to 50 mg once daily at bedtime) may be given for the first 2 weeks of treatment. If there is no improvement after 1 week, change to diazepam PO (2.5 to 5 mg 2 times daily) for 2 weeks max. 

During the first 2 to 4 weeks, do not give the patient more tablets than the quantity required for each week or entrust the treatment to someone in the patient's close entourage that can initially ensure administration of the drug.

Severe depression carries the risk of suicide. Talking to patients about this will not increase the risk of suicide attempt. On the contrary – depressed people are often anxious and ambivalent about suicide and feel relieved when able to talk about it.

If major symptoms have not improved after a month of treatment, increase to the maximum dose and assess after 2 weeks. If there is no improvement, refer the patient to a psychiatrist, if possible; if not, try a different antidepressant.

The treatment should always be stopped gradually over a 4-week period. Inform the patient about problems associated with abrupt treatment discontinuation (very common with paroxetine).

Special situations: pregnant or breast-feeding women

• Pregnancy in a woman under antidepressants:

Re-evaluate the need to continue treatment. If treatment is still necessary, it is best to continue a treatment that has been effective rather than switching to a different antidepressant. Nevertheless, if the woman plans to breastfeed and is taking fluoxetine, consider switching to another SRI at least 3 weeks before expected delivery to reduce adverse effects in the neonate during breastfeeding. Monitor the neonate the first few days of life for signs of toxicity or withdrawal symptoms.

• Depression occurring during pregnancy or during post-partum period:

Depression is more frequent in the post-partum (breast-feeding) period than in pregnancy. In case of severe post-partum depression in a breast-feeding woman: use sertraline as first-line option, or if not available, use paroxetine: do not administer fluoxetine. In case of severe depression during pregnancy: use sertraline, avoid paroxetine.