Depressive Disorders

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Click here to access the Primary Healthcare Chapter 15: Central Nervous System Conditions with supporting NEMLC Report_2020-4 Review_Version 1.0_26 May 2025

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Description

General Measures

Medicine Treatment

Referral

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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 cause significant impairment in social and occupational functioning, and may result in unemployment, poor self-care, neglect of dependent children, and suicide
• Depression impacts negatively on other medical conditions, with increased pain, disability and poorer treatment outcomes
• Depression is characterised by a low mood and/or a reduced capacity to enjoy life. Depressive episodes may also occur as part of Bipolar Disorder, which requires a different treatment strategy to the other depressive disorders
• Depression is often not recognised by the sufferer or clinicians. 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. In general, insomnia and loss of energy are the most common presenting complaints. In African cultures, somatic symptoms (bodily aches and pains) may predominate. 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

Depression may present with: 

• Mood symptoms: may manifest as depressed, sad, hopeless, discouraged, feeling empty, having no feelings, irritability, increased anger or frustration, bodily aches and pains 
• Loss of interest or pleasure (anhedonia): ‘not caring any more’, boredom, social withdrawal, apathy, reduced sexual interest or desire 
• Neuro-vegetative symptoms: loss of appetite or an increase in appetite, sometimes with food cravings; weight loss or gain if appetite changes are severe; increased or decreased sleep (usually mid- or terminal-insomnia, i.e. waking during the night or early hours of the morning); psychomotor agitation (pacing, hand-wringing, rubbing of skin or clothing) or psychomotor retardation (slowed thoughts, speech and/or movements); tiredness and fatigue – daily living tasks, e.g. getting dressed, are exhausting 
• Psychological symptoms: feelings of worthlessness, unrealistic negative self-evaluation, self-blame and guilt – may be over minor failings or may be of delusional proportions 
• Cognitive symptoms: diminished ability to think, concentrate or make minor decisions; may appear to be easily distracted; memory may be impaired (as in pseudodementia); preoccupation with thoughts of death of loved ones, others or self (from vague wishes to suicidal ideation or plans) 

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.

GENERAL MEASURES

• Assess severity of the condition
• Maintain an empathic and concerned attitude
• Exclude underlying medical conditions and optimise treatment for comorbid conditions (e.g. hypothyroidism, anaemia, HIV/AIDS, TB, cancers, diabetes)
• Screen for and manage underlying or co-morbid substance use, e.g. nicotine, alcohol, over the counter analgesics, benzodiazepines
• Explore and address psychosocial stressors: 
  • Stress management/ coping skills – refer to counselling services
  • Relationship and family issues – refer to counselling services. Refer to a social worker if abuse is evident
  • Accommodation and vocational issues; refer to labour/ social development
  • Assess social support and refer to a social worker if financial difficulty

MEDICINE TREATMENT

Offer choice of psychotherapy (if available) or medication. 

Adults

• Fluoxetine, oral
  • Initiate at 20 mg alternate days for 2 weeks
  • Increase to 20 mg daily after 2–4 weeks
  • Delay dosage increase if increased agitation/ panicky feelings occur
  • Reassess response after 4 weeks on daily fluoxetine. Symptoms may take up to 2-4 weeks to resolve. If only a partial or no response after 8 weeks of treatment refer to doctor
  • See note below for treatment duration

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OR

If fluoxetine is poorly tolerated: 

• Alternative SSRI e.g.: 
• Citalopram, oral.
  • Initiate at 10 mg daily for the 1^st week
  • Then increase to 20 mg daily

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CAUTION - SSRIs (e.g. fluoxetine, citalopram) may cause agitation during the first 2–4 weeks - Ask about suicidal ideation in all patients, particularly adolescents and young adults. (See: Suicide Risk Assessment) -  If suicidal ideation present, refer before initiating SSRI - 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

If a sedating antidepressant is required:

• Tricyclic antidepressants, e.g.: (Doctor initiated) 
• 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

CAUTION - Tricyclic antidepressants can be fatal in overdose - Prescription requires a risk assessment of the patient and others in their household, especially adolescents - Avoid tricyclic antidepressants in the elderly and patients with heart disease, urinary retention, glaucoma and epilepsy

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Note:

- Continue treatment for a minimum of 9 months. Consider stopping only if patient has had no/minimal symptoms and has been able to carry out routine daily activities. 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)

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CAUTION - Do not prescribe antidepressants to a patient with bipolar disorder without consultation, as antidepressants may precipitate a manic episode - Be careful of interactions between antidepressants and any other agents that the patient might be taking (e.g. St John’s Wort or traditional African medicine)

REFERRAL

• Suicidal ideation
• Major depression with psychotic features
• Bipolar disorder
• Failure to respond to antidepressants
• Pregnancy and lactation
• Children and adolescents

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare Level, 2020 Edition