Depression

Depression is characterised by a set of symptoms lasting at least two weeks and causing a change from the patient’s previous functioning.

The classic diagnostic criteria for a major depressive episode 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 loss of 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
• Feeling of guilt or worthlessness, loss of self-confidence or self-esteem
• Feeling of despair
• Thoughts of death, suicidal ideation or attempt

The features of depression can vary, however, from one culture to another1 . 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. rape, recent childbirth and post-partum depression).

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

Symptoms of depression are common directly after a major loss (bereavement, exile, etc.). They gradually subside, in most cases, with support from relatives. Psychological support may be useful.

Pharmacological treatment is justified if there is a risk of suicide or in the event of severe or long-lasting problems with significant impact on daily life, or if psychological follow-up alone is not enough.

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

Preferably use a serotonin reuptake inhibitor (SRI), particularly in elderly patients:
fluoxetine PO: 20 mg once daily in the morning (max. 40 mg daily); use with caution in patients with severe anxiety disorders or who are immobilised (e.g. wounded)
or
paroxetine PO: 20 mg once daily at bedtime (max. 40 mg daily), especially if the depression is accompanied by severe anxiety
or
sertraline PO: 50 mg once daily during a meal (max. 100 mg daily)

If the response is insufficient after 4 weeks and the SRI is well tolerated, increase the dose. If the SRI is poorly tolerated, replace with another SRI without waiting any interval between the two.
If antidepressants 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 elderly 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 increased, especially with fluoxetine. Diazepam PO (2.5 to 5 mg 2 times daily) may be given for the first 2 weeks of treatment.

During the first month, the patient should be followed weekly. During this period, 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.

All serious 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 resolved at all after a month at a normally-effective dose, 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:
It is always preferable to stop treatment. If it is necessary to pursue treatment, continue normal treatment. Nevertheless, if the woman is taking paroxetine, change to sertraline.

– Depression during pregnancy or during postpartum period:
Depression is more frequent in the postpartum (breast-feeding) period than in pregnancy. In case of severe postpartum depression in a breast-feeding woman: use paroxetine, do not administer fluoxetine. In case of severe depression during pregnancy: use sertraline, avoid paroxetine.



Footnotes
Ref Notes
1 Hence the importance of working with an “informant” (in the anthropological sense of the word) when dealing with unfamiliar cultural contexts.