Depressive Disorders

Description

General measures

Medicine treatment

Referral

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ICD-10 code: F32.0-3/F32.8-9/F33.0-4/F33.8-9/F34.1 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0- 4/Z81.8)

Description

Depressive disorders may occur as single or recurrent episodes, as a chronic, persistent low mood, or a combination of the two. Depressive disorders differ from bipolar disorder, in that there is no history of manic, hypomanic, or mixed episodes.

Depressive disorders cause significant impairment in social and occupational functioning, and may result in unemployment, poor self-care, neglect of dependent children, and suicide. They may be comorbid with, or secondary to, other medical illness or substance use. Depression impacts negatively on comorbid conditions, with increased pain, disability, and poorer treatment outcomes.

Depression is characterised by a low mood and/or a reduced capacity to enjoy life. However, it is often not recognised by the sufferer or clinician. It may be regarded as a normal emotional state or it may be unacceptable to the sufferer due to stigma. Thus, associated symptoms may be the presenting complaint rather than the low mood. Symptoms may also be masked in the interview setting. It is important to have a high degree of suspicion and to elicit symptoms, degree of impaired function, and suicide risk with care.

• In general, insomnia and loss of energy are the most common presenting complaints. In African cultures, somatic symptoms (bodily aches and pains) and rumination (‘thinking too much’) may predominate.
• The presence of mood, psychological, and cognitive symptoms help to differentiate between depression and normal sadness following a loss, or the loss of appetite and energy associated with a medical condition.
• Psychotic symptoms (delusions, hallucinations, or thought disorder) are usually mood congruent and indicate marked severity and a high risk to self or others.

Depression during pregnancy and the postnatal period is associated with preterm delivery, low-birth weight babies, poor maternal self-care, impaired mother-infant engagement, and poor psychological and neurodevelopmental outcomes in the child. Risk of negative impact is increased depending on severity (See PHC STGs and EML, Maternal mental health).

General Measures

• Maintain an empathic and concerned attitude.
• Discuss uncertainty with a specialist at any point in the care pathway.
• Assess severity of the condition and suicide risk. See PHC STGs and EML: Suicide risk assessment.
• Exclude and optimise treatment of underlying and/or comorbid medical conditions (e.g. hypothyroidism, anaemia, HIV/AIDS, TB, cancers, diabetes).
• Screen for, and manage, underlying or comorbid substance use, e.g. nicotine, alcohol, over the counter analgesics, benzodiazepines.
• Screen for bipolar disorder and comorbid psychiatric disorders – refer for specialist assessment.
• Explore and address psychosocial stressors:
  • Stress management / coping skills – refer to registered counsellors, social worker, and/or occupational therapy.
  • Relationship and family issues – refer to social worker, registered counsellors, Non-Governmental Organisation (NGO) counselling, e.g. FAMSA (www.famsa.org.za).
  • If abuse, intimate partner, or other violence is evident, refer to a social worker.
• Provide self-help literature, where available, and refer to local support groups, e.g. SADAG (www.sadag.org).

Medicine Treatment

• Offer choice of psychotherapy (if available) or medication.
• Antidepressants take 4–6 weeks to achieve their maximum effect. There is little evidence to support combination medicine treatment.
• Tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors (SSRIs) are of equal efficacy.
• Electroconvulsive therapy (ECT) (specialist administered) is indicated under specific circumstances, e.g. severe depression, in pregnancy.
• The choice of therapy is guided by comorbid states, risk of overdose, and patient response.
• Refer to occupational therapy if available for vocational rehabilitation.

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CAUTION - ANTIDEPRESSANTS

- SSRIs (e.g. fluoxetine, citalopram) may cause agitation and an increased suicide risk during the first 2–4 weeks.
- Once started, monitor closely for clinical worsening, suicidality, or unusual changes in behaviour. Advise families and caregivers of the need for close observation and refer as required.
- TCAs can be fatal in overdose. Prescription requires a risk assessment of the patient and others in their household, especially adolescents. See: Tricyclic antidepressant poisoning.
- Avoid TCAs in the elderly and in patients with heart disease, urinary retention, glaucoma, and epilepsy.
- Do not prescribe antidepressants to a patient with bipolar disorder without consultation, as they may precipitate a manic episode.
- Be aware of interactions between antidepressants and other agents (e.g. other medicines, St John’s Wort or traditional African medicine)

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PREGNANCY AND BREASTFEEDING
- SSRI treatment of depression in pregnancy is associated with improved symptoms in the mother and better emotional and psychological development of the child. Benefit is greater with increasing illness severity. Effect of SSRIs in pregnancy on anxiety is less clear.
- Lack of matched case-control studies mean harms of treatment are unclear.
- If stable on an SSRI, do not stop – discuss risk/benefit with mother.
- Index presentations: offer counselling and psychotherapy; discuss risk/benefit of SSRIs.
- Refer social worker to explore social and financial support systems.
- Avoid fluoxetine due to long half-life and relatively high concentration in breastmilk. Consider citalopram as alternative.
- All antidepressants: possible increased risk of miscarriage, transient neonatal symptoms (jitteriness, irritability), and persistent pulmonary hypertension of the newborn.
- Avoid benzodiazepines – some association with neurodevelopmental delay in the child; neonatal sedation if used late in pregnancy.

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LoE:IVb^xxvi

• Selective serotonin reuptake inhibitor (SSRI), e.g.:
• Fluoxetine, oral.
  • Initiate at 20 mg alternate days for 2–4 weeks.
  • Thereafter, increase to 20 mg daily. Delay dosage increase if agitation/panic symptoms, suicidal ideation occur.
  • Reassess response after 4–6 weeks. o If partial response: increase to 40 mg daily and/or augment with psychotherapy.
  • If no response: consult with specialist (re-evaluate diagnosis, repeat general measures, prescribe alternative SSRI, psychotherapy, or ECT).

If fluoxetine is poorly tolerated

• Alternative SSRI e.g.:
• Citalopram, oral.
  • Initiate at 10 mg daily for the 1st week.
  • Then increase to 20 mg daily.
  • If partial response: increase to 40 mg daily (except in cardiac disease and >65 years) and/or augment with psychotherapy.
  • If no response: consult with specialist (re-evaluate diagnosis, repeat general measures, prescribe alternative SSRI, psychotherapy, or ECT).

LoE:Ib^xxvii

If sedating antidepressant is required:

• Amitriptyline, oral, at bedtime.
  • Initial dose: 25 mg per day.
  • Increase by 25 mg per day at 3–5 day intervals.
  • Maximum dose: 150 mg per day.
  • If no response: discuss with specialist (re-evaluate diagnosis, repeat general measures, prescribe alternative SSRI, psychotherapy, or ECT).

LoE:IVb^xxviii

Treatment duration
Continue for a minimum of 9 months. Consider stopping only if patient has had no/minimal symptoms and can carry out routine daily activities. Taper medicine slowly to avoid discontinuation symptoms; reinstitute if there is a recurrence.

Prolong treatment if:

• Concomitant generalised anxiety disorder (extend treatment to at least 1 year).
• Previous episode/s of depression (extend treatment to at least 3 years).
• Any of: severe depression, suicidal attempt, sudden onset of symptoms, family history of bipolar disorder (extend treatment to at least 3 years).
• If ≥3 episodes of depression advise lifelong treatment.

LoE:IIb^xxix

Referral

• Inadequate response to treatment.
• High suicide risk.
• Psychotic features.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults_Chapter 15: Mental Health Conditions and Substance Misuse_NEMLC Recommendations for Medicine Amendments 2020-2023