Protocol · WHO mhGAP
Depression (mhGAP)
Depression is common, treatable and often hidden behind tiredness, poor sleep or unexplained aches. Ask about mood and interest, check for suicide risk, rule out bipolar disorder and physical causes, then offer support and psychological help, adding an antidepressant when needed.
- Based on WHO mhGAP
- For doctors, clinical officers, nurses and trained community workers
- Reviewed October 2026
1Who / when
- Adults with persistent sadness, loss of interest, low energy, poor sleep, or many physical symptoms with no clear cause.
- Children and adolescents: use the mhGAP child and adolescent module; fluoxetine only from age 12 and with weekly checks at first.
2Red flags: refer now
- Imminent risk of suicide: current thoughts or plan, or a recent act of self-harm. Manage this first (see the self-harm protocol).
- Psychotic symptoms (delusions or hallucinations) with depression.
- Past mania: symptoms of bipolar disorder.
- Not eating or drinking, or unable to care for self.
Suicide risk comes firstDo not leave a person at imminent risk alone. Remove means of self-harm and consult a specialist where available.
3Assess
Is it depression?
- For at least 2 weeks, at least one of: persistent low mood; markedly reduced interest or pleasure.
- And several of: poor or too much sleep; appetite or weight change; worthlessness or excessive guilt; tiredness; poor concentration; indecision; agitation or slowness; hopelessness; suicidal thoughts or acts.
- And considerable difficulty with daily life: home, work, school or social.
Other explanations
- Physical causes: anaemia, malnutrition, hypothyroidism, substance use, medicines (for example steroids). Treat them and reassess.
- Past mania: at least a week of raised or irritable mood, little need for sleep, overactivity, fast speech, reckless behaviour. If so, this is bipolar depression: see Treat.
- Major loss in the last 6 months (such as bereavement): do not treat as depression unless there is slowness, suicidal thinking, worthlessness, psychotic symptoms, or a past history of depression.
- Check for alcohol or drug use and other mental health conditions.
4Classify
| Picture | Classify as | Action |
|---|---|---|
| Thoughts or plan of suicide, or recent self-harm | Imminent suicide risk | Self-harm protocol first |
| Depression with past mania | Depressive episode in bipolar disorder | Consult a specialist; no antidepressant alone |
| Criteria met; psychotic symptoms present | Depression with psychotic features | Consult a specialist |
| Criteria met | Depression | Protocol below |
| Criteria not met, or normal grief | Depression unlikely | Support; reassess if not improving |
5Treat
For everyone
- Psychoeducation for the person and carers (see Counsel).
- Reduce stress and rebuild social support; restart activities that used to give pleasure.
- Offer a structured psychological treatment where trained staff are available: behavioural activation, problem-solving, CBT, interpersonal therapy (for example WHO Problem Management Plus or group IPT).
- Do not give vitamin injections or other ineffective treatments.
Antidepressants (moderate to severe depression)
Decide together. WHO suggests psychological treatment or combined treatment by preference; antidepressants alone only when psychological help is not available. Start one medicine at the lowest dose.
| Medicine | Adult dose (mhGAP-IG) | Notes |
|---|---|---|
| Fluoxetine (SSRI) | 10 mg daily for 1 week, then 20 mg daily. No response in 6 weeks: 40 mg (maximum 80 mg) | First choice with suicidal thoughts, older or medically ill people (older adults: maximum 40 mg). Bleeding risk with aspirin or NSAIDs |
| Amitriptyline (tricyclic) | 25 mg at bedtime; increase by 25 to 50 mg a week to 100 to 150 mg (minimum effective dose 75 mg) | Not with heart disease, suicide risk, seizures, glaucoma, urinary retention. Overdose can kill. Not under 18 |
- Pregnancy or breastfeeding: avoid antidepressants if possible; if needed, lowest effective dose; avoid fluoxetine when breastfeeding; consult a specialist.
- Bipolar depression: never an antidepressant without a mood stabiliser. If mania develops, stop the antidepressant at once.
6Follow-up
- Second appointment within 1 week. Then regular contact (for example monthly) for the first 3 months; less often as the person improves.
- Each contact: mood, suicide risk, side effects, adherence, social support.
- Not improving: check adherence; increase the dose if tolerated and review in 1 to 2 weeks; add psychological treatment.
- Continue an antidepressant that works for at least 9 to 12 months after symptoms resolve (WHO 2023: at least 6 months after remission). Then taper over at least 4 weeks and watch for relapse.
7Counsel
- Depression is a common health condition. It is not weakness or laziness, and it can be treated.
- Hopeless thoughts are part of the illness and usually lift as it improves.
- Try to keep regular sleep, eat regularly, be active, and spend time with trusted people.
- Antidepressants are not addictive, take several weeks to work, and should not be stopped just because you feel better.
- If you have thoughts of harming yourself, tell someone you trust and come back straight away.
What you are going through is an illness called depression. It is common and it gets better with treatment. If you ever think of ending your life, please tell someone and come back to us straight away.
8When to refer
- Same day: imminent suicide risk that cannot be kept safe in the community.
- Depression with psychotic symptoms, or bipolar depression.
- No response after adequate dose, duration and psychological support.
- Pregnant or breastfeeding women needing medicine; adolescents; considering pregnancy while on treatment.
9Sources
- World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. 2016 (ISBN 9789241549790). Depression module (DEP 1 to 3) and Table 1 doses.
- World Health Organization. Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. 2023 (ISBN 9789240084278). Recommendations DEP1 to DEP4.
- World Health Organization. WHO Model List of Essential Medicines. 2025.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.