Low mood and poor sleep
People with depression often come with a physical complaint: poor sleep, tiredness, aches. If you treat only the sleep, you miss the illness. Ask about mood and interest, ask about suicide, look for a physical cause and for past mania, then make a plan with the person.
- Setting: Primary health centre with an mhGAP-trained nurse and a monthly visiting mental health officer
- For nurses, clinical officers and doctors at first-level facilities trained in mhGAP
- Reviewed October 2026
The presentation
Esther, 41, sells vegetables at the market. She asks for 'something to make me sleep'. For about 2 months she has woken at 3 or 4 in the morning and cannot get back to sleep. She feels exhausted all day. Her husband lost his job 6 months ago and they are in debt.
| Vital sign | Value |
|---|---|
| Blood pressure | 118/76 mmHg |
| Pulse | 76 per minute |
| Weight | 61 kg (66 kg a year ago) |
| Temperature | 36.6 °C |
Tests at hand: Haemoglobin (Hb) · Urine pregnancy test · HIV rapid test · Blood glucose (finger-prick)
- DepressionStill possible
- Imminent risk of suicide Must not missStill possible
- Depressive episode in bipolar disorder Must not missStill possible
- Depression with psychotic features Must not missStill possible
- Reaction to stress, without depressionStill possible
- Physical cause (anaemia, thyroid, HIV, medicines)Still possible
- Alcohol or other substance useStill possible
- Anxiety disorderStill possible
Work through it
Read each question and decide your own answer first. Then open the model answer and see how the differential changes.
- Step 1 of 7 · Ask
Before you think about sleeping tablets: what are the two core questions for depression?
Model answer
mhGAP asks whether the person has had at least one of these for at least 2 weeks:
- Persistent depressed mood.
- Markedly diminished interest in, or pleasure from, activities.
Ask in plain words, and give her time: 'How has your mood been? Do you still enjoy the things you used to?'
Esther cries. She says she has felt sad 'all the time' since about 3 months ago, and no longer enjoys church or seeing her sisters. She stopped going to the women's savings group.
Differential now- DepressionLeading (moved up)
- Imminent risk of suicide Must not missStill possible
- Depressive episode in bipolar disorder Must not missStill possible
- Depression with psychotic features Must not missStill possible
- Physical cause (anaemia, thyroid, HIV, medicines)Still possible
- Alcohol or other substance useStill possible
- Anxiety disorderStill possible
- Reaction to stress, without depressionLess likely (moved down)
- Step 2 of 7 · Ask
What else do you ask to decide whether this is depression? How does daily functioning come in?
Model answer
Ask about the additional symptoms, present for at least 2 weeks: disturbed sleep or sleeping too much; change in appetite or weight; worthlessness or excessive guilt; fatigue or loss of energy; poor concentration; indecisiveness; agitation or restlessness; talking or moving more slowly; hopelessness; suicidal thoughts or acts.
Then ask about functioning: does she have considerable difficulty with daily life at home, work or in the community?
Esther wakes early, has little appetite and has lost 5 kg, feels useless and blames herself for the debt, cannot concentrate on counting money at the stall, and feels hopeless. She now opens the stall only 3 days a week. She meets the mhGAP picture of depression: core symptoms, several additional symptoms, and considerable difficulty in daily functioning.
Differential now- DepressionLeading
- Imminent risk of suicide Must not missStill possible
- Depressive episode in bipolar disorder Must not missStill possible
- Depression with psychotic features Must not missStill possible
- Physical cause (anaemia, thyroid, HIV, medicines)Still possible
- Alcohol or other substance useStill possible
- Reaction to stress, without depressionLess likely
- Anxiety disorderLess likely (moved down)
- Step 3 of 7 · Ask
How do you ask about suicide, and what would make the risk imminent?
Model answer
Ask directly and calmly. Asking does not put the idea in her head. 'Sometimes when people feel like this they think about ending their life. Have you had thoughts like that?' If yes: 'Have you made a plan? Do you have the means? Have you ever harmed yourself?'
The risk is imminent with current thoughts or a plan of suicide, a recent act of self-harm, or extreme agitation, violence or distress. Then the self-harm protocol comes first: do not leave her alone, remove means, and get help.
Esther says she has thought that her children would be better off without her, but she has no plan and has never harmed herself. 'I could not leave my children.' The risk is not imminent today, but it must be asked again at every visit.
Differential now- DepressionLeading
- Depressive episode in bipolar disorder Must not missStill possible
- Depression with psychotic features Must not missStill possible
- Physical cause (anaemia, thyroid, HIV, medicines)Still possible
- Alcohol or other substance useStill possible
- Imminent risk of suicide Must not missLess likely (moved down)
- Reaction to stress, without depressionLess likely
- Anxiety disorderLess likely
- Step 4 of 7 · Ask
Which other conditions must you rule out before treating depression?
Model answer
- Past mania (bipolar disorder): at least a week of elevated or irritable mood with decreased need for sleep, much more energy and talk, reckless spending or behaviour. Antidepressants alone can trigger mania.
- Psychotic symptoms: hearing voices, fixed false beliefs. If present, treatment must be adapted with a specialist.
- Alcohol, other substances and medicines, including steroids.
- Physical conditions that can resemble or worsen depression: anaemia, malnutrition, hypothyroidism, HIV and other chronic illness.
- Recent major loss: normal grief is not treated as depression.
No episode of high mood or reduced need for sleep. No voices or strange beliefs. She does not drink alcohol and takes no medicines. Her periods are regular but heavy. No recent bereavement. On examination: no goitre, normal pulse and reflexes, palms slightly pale.
Differential now- DepressionLeading
- Physical cause (anaemia, thyroid, HIV, medicines)Still possible
- Imminent risk of suicide Must not missLess likely
- Reaction to stress, without depressionLess likely
- Anxiety disorderLess likely
- Depressive episode in bipolar disorder Must not missSet aside for now (moved down)
- Depression with psychotic features Must not missSet aside for now (moved down)
- Alcohol or other substance useSet aside for now (moved down)
- Step 5 of 7 · Test
Which bedside tests are worth doing, and why?
Model answer
- Haemoglobin: heavy periods and pale palms. Anaemia causes tiredness and can make depression worse.
- Pregnancy test: before starting an antidepressant in a woman of childbearing age.
- HIV rapid test, offered with consent: HIV is a physical condition linked to depression, and treatment changes.
- Glucose is not needed: she has no symptoms of diabetes.
Results: Hb 11.2 g/dL (mild anaemia). Pregnancy test negative. HIV test negative.
Mild anaemia does not explain 3 months of low mood, loss of interest and hopelessness. Treat both.
Differential now- DepressionLeading
- Imminent risk of suicide Must not missLess likely
- Reaction to stress, without depressionLess likely
- Physical cause (anaemia, thyroid, HIV, medicines)Less likely (moved down)
- Anxiety disorderLess likely
- Depressive episode in bipolar disorder Must not missSet aside for now
- Depression with psychotic features Must not missSet aside for now
- Alcohol or other substance useSet aside for now
- Step 6 of 7 · Do
What is your plan? What about the sleeping tablets she asked for?
Model answer
Depression, without imminent suicide risk, psychosis or bipolar disorder. It can be managed at the health centre by an mhGAP-trained worker.
- Psychoeducation: depression is a common illness, not weakness or laziness; it can be treated.
- Address stressors: the debt and her husband's job. Link her to any social or livelihood support available; problem-solving about one small step.
- Reactivate social networks and activity: restart the savings group or church, regular physical activity, regular meals.
- Sleep: regular sleeping and waking times, the same every day.
- Psychological treatment where trained staff exist: behavioural activation, problem-solving, or WHO Problem Management Plus or group interpersonal therapy.
- Antidepressant: discuss and decide together. If chosen, fluoxetine 10 mg daily for a week, then 20 mg daily (mhGAP). Explain that it is not addictive, takes several weeks to work, and must not be stopped suddenly.
- Iron for the anaemia, per national formulary, and review the heavy periods.
Not a sleeping tabletSleeping tablets do not treat depression. Benzodiazepines can cause dependence, sedation and withdrawal; do not use them as the treatment for low mood and early waking.Differential now- DepressionLeading
- Imminent risk of suicide Must not missLess likely
- Reaction to stress, without depressionLess likely
- Physical cause (anaemia, thyroid, HIV, medicines)Less likely
- Anxiety disorderLess likely
- Depressive episode in bipolar disorder Must not missSet aside for now
- Depression with psychotic features Must not missSet aside for now
- Alcohol or other substance useSet aside for now
- Step 7 of 7 · Ask
How do you follow her up, and what do you agree before she leaves?
Model answer
- A second appointment within 1 week, then regular contact for the first 3 months.
- At every contact: mood, suicidal thoughts, side effects, whether she is taking the medicine, and her support.
- A safety plan: who she will tell, and to come back at once, day or night, if thoughts of ending her life become stronger or she makes a plan.
- If an antidepressant works, continue it for at least 9 to 12 months after she recovers, then reduce slowly.
- Not improving after an adequate trial and psychological support: consult the visiting mental health officer.
What you are going through is depression. It is a common illness and it can get better. We will work on it together: small steps, the people around you, and if you agree, a tablet that takes a few weeks to help. If you ever feel you might harm yourself, come here or tell your sister straight away.
Must-not-miss conditions
| Condition | Clues | What to do at first-level care |
|---|---|---|
| Imminent risk of suicide | Current thoughts or plan of suicide, recent self-harm, access to means, extreme agitation or hopelessness. | Do not leave the person alone; remove means; self-harm protocol; consult a specialist; same-day referral if she cannot be kept safe. |
| Depressive episode in bipolar disorder | Past week or more of elevated or irritable mood, reduced need for sleep, overactivity, reckless behaviour. | No antidepressant alone; consult a specialist. |
| Depression with psychotic features | Hallucinations or delusions with low mood. | Consult a specialist; adapted treatment. |
| Physical illness presenting as low mood | Anaemia, thyroid disease, HIV, TB, malnutrition, steroid or other medicines, alcohol. | Examine, test and treat the physical condition; reassess mood after treatment. |
Decision at first-level care
Esther has depression (mhGAP criteria met, with considerable difficulty in daily functioning), triggered by financial stress, with passive thoughts of death but no plan and no imminent risk. Bipolar disorder, psychosis and alcohol use are excluded; mild anaemia is treated alongside. She is managed at the health centre with psychoeducation, stress reduction, social reactivation and psychological support, with fluoxetine if she chooses, and follow-up within a week.
Source: WHO mhGAP Intervention Guide, version 2.0 (2016); WHO mhGAP guideline (2023).
- mhGAP criteria for depression met, no imminent suicide risk, no psychosis or past mania: psychosocial interventions, with or without an antidepressant.
- Physical cause found and treatable: treat it, then reassess mood.
- Distress after a stressor without the criteria for depression: support, problem-solving, review in 2 to 4 weeks.
- Normal grief after a bereavement: support; reassess if not easing.
- Imminent risk of suicide that cannot be managed safely in the community: the same day.
- Depression with psychotic symptoms, or a history of mania.
- No improvement after an adequate dose, duration and psychological support.
- Pregnant or breastfeeding and needing medicine; adolescents.
Key learning points
- Sleep problems, tiredness and aches are common ways depression first presents: always ask about mood and interest.
- mhGAP depression: a core symptom for 2 weeks, several additional symptoms, and difficulty with daily functioning.
- Ask everyone with depression directly about suicide, and again at every visit.
- Check for past mania and psychosis before starting an antidepressant.
- Psychological and social interventions come first; sleeping tablets are not a treatment for depression.
Sources
- World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. 2016. DEP module: core and additional symptoms for 2 weeks, daily functioning, physical conditions that resemble depression (anaemia, malnutrition, hypothyroidism, medicines), history of mania, psychotic features, psychosocial interventions (psychoeducation, stress reduction, reactivating social networks, regular sleep and activity), fluoxetine starting dose, duration 9 to 12 months, follow-up; SUI module: asking about suicide, imminent risk; substance use module: benzodiazepine dependence and withdrawal.
- World Health Organization. Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. 2023. Psychological interventions for depression; antidepressant options (as summarised in the depression protocol).
- World Health Organization. Problem Management Plus (PM+): individual psychological help for adults impaired by distress in communities exposed to adversity. 2016. Scalable psychological intervention named in mhGAP-IG 2.0.
- World Health Organization. Guideline on haemoglobin cutoffs to define anaemia in individuals and populations. 2024. Non-pregnant women: anaemia below 12.0 g/dL; mild 11.0 to 11.9 g/dL.