Depression

Clinical assessment

Diagnosis based on clinical interview assessing presence, duration, and severity of characteristic symptoms and functional impairment. Requires symptoms present for at least 2 weeks. Assess for history of mania/hypomania (to rule out bipolar disorder). Assess for psychotic features. Assess suicide risk. Screen for co-occurring physical conditions and substance use.

Investigations

• Usually diagnosed clinically.
• Medical, social, personal history including bereavement/loss assessment.
• Consider investigations to rule out organic causes mimicking depression: Thyroid function tests (hypothyroidism), CBC (anemia), HIV test, screening for other chronic illnesses based on presentation.

Diagnostic criteria

Based on diagnostic criteria (e.g., ICD, DSM) requiring a certain number of core and other symptoms present for at least 2 weeks causing significant distress or functional impairment. Rule out bipolar disorder, substance-induced mood disorder, mood disorder due to another medical condition, and normal bereavement.

Non-pharmacological management

• First line for mild depression:
• - Psychoeducation (patient and family counselling).
• - Addressing current stressors (problem-solving, support).
• - Reactivating social networks and support.
• - Structured physical activity / exercise.
• - Regular follow-up.
• Psychotherapy (if available, effective for mild-moderate): Cognitive Behavioural Therapy (CBT), Interpersonal Therapy (IPT), Behavioural Activation.
• Bereavement Counselling: Provide support, do not use drugs/psychotherapy as first line for normal grief.

Pharmacological treatment

• Antidepressants (Consider for moderate-severe depression or mild depression unresponsive to non-pharmacological approaches):
• - SSRIs (Selective Serotonin Reuptake Inhibitors) - Often first line:
• - Fluoxetine: 20mg daily AM (start 10mg in elderly). Increase to 40mg after 4-6 weeks if needed.
• - Sertraline: 50mg daily (preferred if on other meds due to low interactions, safe in breastfeeding). Increase by 25-50mg increments weekly if needed (max 200mg/d).
• - Escitalopram: 10mg daily, may increase to 20mg daily.
• - TCAs (Tricyclic Antidepressants):
• - Amitriptyline: 50mg nocte initially, increase by 25mg weekly aiming for 100-150mg (divided or single PM dose). Useful if co-existing anxiety/insomnia. Avoid in adolescents, elderly, heart disease, high suicide risk due to overdose toxicity.
• - SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors):
• - Venlafaxine: Start 37.5mg daily, increase to 75mg daily (divided doses), maintenance 75-225mg daily (max 375mg). Useful for comorbid anxiety.
• - Other:
• - Bupropion: 150mg daily, titrate up to 450mg/day. Useful if comorbid nicotine dependence, less sexual side effects.
• General Principles: Choose based on side effect profile, comorbidities, availability, cost. Takes 2-4 weeks for initial effect, 4-8 weeks for full effect. Continue treatment for at least 9-12 months after remission to prevent relapse. Taper dose slowly over at least 4 weeks when discontinuing to avoid withdrawal symptoms.
• Caution: DO NOT use antidepressants in children <12 years. Use ONLY under specialist supervision in adolescents. SSRIs can trigger mania in undiagnosed bipolar disorder. Refer pregnant women to specialist.
• Follow specific Ugandan treatment algorithms/guidelines.

Monitoring

Monitor symptoms (mood, interest, energy, sleep, appetite, suicidal ideation) regularly (e.g., every 1-2 weeks initially, then monthly). Monitor functional improvement. Monitor for side effects (e.g., GI upset, headache, sexual dysfunction with SSRIs; sedation, dry mouth, constipation, cardiotoxicity with TCAs). Assess adherence. Monitor for emergence of mania/hypomania. Assess suicide risk regularly.