Recognising and managing depression (mhGAP)

Key messages to land

1. Depression is common, often presents with physical complaints, and is treatable in general clinics.
2. Use the three-part check: core symptom for 2 weeks, other symptoms, difficulty functioning.
3. Always look for physical causes and ask about mania before treating.
4. Asking about suicide does not provoke it. Ask everyone with depression.
5. Psychological treatment first where available; an antidepressant alone only where it is not.
6. Follow up within 1 week; continue antidepressants for 9 to 12 months after recovery.

Running the role-plays

• Keep triads to 3 people: person, health worker and observer. Give the observer a clear checklist so feedback is specific.
• Remind participants they are playing a role. Allow anyone to step out, and be ready to support a participant who becomes upset.
• Encourage the use of local words for distress, as long as the health worker still checks the mhGAP criteria.

Common misunderstandings

"Asking about suicide will put the idea in their head"

mhGAP is clear: asking does not provoke self-harm and often brings relief.

"Depression is weakness"

It is a common illness. Saying so is part of psychoeducation.

"Stop the tablets when they feel better"

Continue for 9 to 12 months after recovery, then taper over at least 4 weeks.

"Vitamin injections help"

They do not treat depression; mhGAP advises against ineffective treatments.

Adapting the session

If no psychological intervention is available locally, spend part of the treatment-planning time on what the team can offer (problem-solving steps, behavioural activation through planned daily activities) and on how to advocate for training. In humanitarian settings, add the mhGAP Humanitarian Intervention Guide and link to the self-harm and suicide protocol.

Case 1: Role-play 1: Mrs W, 'pain everywhere'

Mrs W, 38, has come four times with headaches and body pains. Tests were normal. On open questioning she says she has felt sad nearly every day since her husband left eight months ago, sleeps badly, has no appetite, feels worthless, and has stopped selling at the market. She has never had periods of unusual energy. She has no thyroid symptoms, is not anaemic and takes no regular medicines.

1. Does she meet the mhGAP criteria for depression?
   Answer: Yes: depressed mood for more than 2 weeks, several other symptoms (sleep, appetite, worthlessness), and difficulty functioning (stopped working). Her loss was eight months ago, more than six months, and physical causes and mania have been considered.
2. What must the health worker ask next?
   Answer: About thoughts, plans or acts of self-harm or suicide, and about alcohol or other substance use.

Case 2: Role-play 2: Mr X, 'better off without me'

Mr X, 52, a farmer with depression, says his family would be better off without him. When asked, he says he has thought of drinking the pesticide stored in his shed, maybe this week. He is calm but tearful.

1. What level of risk is this?
   Answer: Imminent risk of self-harm: a current plan with a method available.
2. What do you do?
   Answer: Do not leave him alone; ask a named family member or staff to stay with him; with his agreement involve the family to remove the pesticide and any stored medicines; offer a quiet safe space; consult a mental health specialist if available; treat the depression; arrange very close follow-up (daily or weekly at first).

Case 3: Planning treatment: Ms Y, 29, after birth

Ms Y had a baby 3 months ago and is breastfeeding. She has moderate depression without thoughts of self-harm. A trained community worker runs Thinking Healthy sessions nearby.

1. What is the first-line plan?
   Answer: Psychoeducation for her and her family, practical support with the baby and sleep, keeping up activities, and referral to Thinking Healthy (a CBT-based programme for perinatal depression). Follow up within 1 week.
2. If she does not improve and an antidepressant is considered, what are the cautions?
   Answer: Avoid antidepressants in breastfeeding if possible; if needed, use the lowest effective dose and avoid long-acting fluoxetine while breastfeeding; consult a specialist if available.

Read the questions aloud or print them. Participants choose one answer each. The answer key with reasons follows.

1. How long must the core symptom of depression be present?
   1. 2 days
   2. At least 2 weeks
   3. 6 months
   4. 1 year
2. Which is NOT a core symptom of depression in mhGAP?
   1. Persistent depressed mood
   2. Markedly reduced interest or pleasure
   3. Hearing voices
3. Before treating depression, what must you rule out?
   1. Physical causes, a history of mania, and normal grief after a recent loss
   2. Nothing
   3. Only pregnancy
   4. Only alcohol use
4. Does asking about suicide increase the risk?
   1. Yes
   2. No; it often reduces anxiety
   3. Only in adolescents
5. A man has a plan to end his life this week. Which action is essential?
   1. Give a 3-month supply of tablets
   2. Remove means and do not leave him alone
   3. Advise rest and review in a month
   4. Tell him not to talk about it
6. What does the 2023 mhGAP guideline say about antidepressant alone for moderate to severe depression?
   1. Always first choice
   2. Only when psychological interventions are not available
   3. Never use
7. Which is a structured psychological treatment recommended for depression?
   1. Vitamin injections
   2. Behavioural activation or problem-solving therapy
   3. Bed rest
8. Which antidepressant should not be used in a person with heart disease?
   1. Fluoxetine
   2. Amitriptyline
   3. Both are equally safe
9. When should the second appointment be?
   1. Within 1 week
   2. In 6 months
   3. Only if the person asks
10. How long should antidepressants usually continue after symptoms resolve?
    1. 2 weeks
    2. 9 to 12 months
    3. 5 years

Answer key

1. B. Depressed mood or loss of interest for at least 2 weeks, with other symptoms and difficulty functioning.
2. C. The two core symptoms are depressed mood and loss of interest or pleasure. Hallucinations suggest psychosis.
3. A. Physical conditions, bipolar disorder (mania) and a major loss within 6 months must be considered.
4. B. mhGAP: asking does not provoke self-harm.
5. B. Imminent risk: remove means, never leave the person alone, consult if possible.
6. B. Psychological or combined treatment; antidepressant alone only when psychological interventions are unavailable.
7. B. Behavioural activation, problem-solving therapy, IPT and CBT are among the structured interventions.
8. B. mhGAP: do not prescribe amitriptyline with cardiovascular disease.
9. A. Schedule the second appointment within 1 week, then regular contact.
10. B. 9 to 12 months, then taper over at least 4 weeks.