Is it depression?
- Low mood or loss of interest, at least 2 weeks.
- Several of: poor or too much sleep, appetite change, worthlessness or guilt, tiredness, poor concentration, slowness or restlessness, hopelessness, suicidal thoughts.
- Difficulty with daily life, work or family.
Rule out
- Physical causes: anaemia, malnutrition, thyroid, substances, medicines.
- Past mania: consult; no antidepressant alone.
- Major loss in last 6 months: grief, unless warning features.
Ask about self-harm
Sometimes when people feel this low, they think about ending their life. Have you had thoughts like that?
Plan or recent act and very distressed: remove means, do not leave alone, consult.
Observer checklist
- Private, introduced, confidentiality explained
- Open questions; listened without interrupting
- Checked the three criteria
- Asked about physical causes and mania
- Asked directly about self-harm
Treat
- Everyone: psychoeducation, reduce stress, social support, daily activities.
- Psychological treatment: behavioural activation, problem-solving, IPT, CBT.
- Antidepressant alone only if no psychological treatment.
- Fluoxetine 10 mg then 20 mg; amitriptyline 25 mg at night rising to 100 to 150 mg (not in heart disease or under 18).
Follow up
- Second visit within 1 week; monthly for 3 months.
- Medicines 9 to 12 months after recovery; taper over 4 weeks.
- Stop antidepressant if mania; consult.
Say it simply
Depression is a common illness, not weakness or laziness. It can get better. If thoughts of harming yourself come, tell someone you trust and come back straight away.
Sources
World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. 2016. World Health Organization. Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. 2023. World Health Organization. mhGAP evidence centre: depression recommendations (2023 update). 2023.