Essential Information for Patient and Family

• Depression is a common illness and effective treatments are available.
• Depression is not weakness or laziness; patients are trying their hardest to cope.

Specific Counselling to Patient and Family

• Ask about risk of suicide. Has the patient talked of death or dying? Does the patient have a specific suicide plan? Has he/she made serious suicide attempts in the past? Can the patient be sure of not acting on suicidal ideas?. Close supervision by family, friends or hospitalization may be needed. Ask about the risk of harm to others.
• Plan short-term activities which give enjoyment or build confidence ( exercise, activity scheduling).
• Encourage the patient to resist pessimism and self-criticism. Do not act on pessimistic ideas (e.g. ending marriage, leaving job). Do not concentrate on negative or guilty thoughts. (cognitive therapy).
• Identify current life problems or social stresses. Focus on small, specific steps patients might take towards reducing or better managing these problems. Avoid major decisions or life changes. Use structured problem solving.
• If many physical symptoms are present, discuss link between physical symptoms and mood (see section on Unexplained Somatic Symptoms).
• After improvement, identify early warning signs of relapse, plan with patient action to be taken if they occur.

Medication

• Consider antidepressant drugs if sad mood or loss of interest are prominent for at least 2 weeks and 4 or more of these symptoms are present: ·
  • Fatigue or loss of energy
  • Disturbed sleep
  • Guilt or self-reproach
  • Poor concentration
  • Thoughts of death or suicide
  • Disturbed appetite
  • Agitation or slowing of movement and speech

  Use medication at first visit of the depression is severe else implement the psychological strategies and review in two weeks, using medication if improvement is marginal.

• Choice of medication

• If good response to one drug in the past, use that again.
• If older or medically ill, use newer medication with fewer side effects.
• If anxious or unable to sleep, use more sedating drug.
  
  
• Build up to effective dose. Commence with an SSRI antidepressant ( citalopram 20 mg, paroxetine 20mg, sertraline 50mg). Start on half a tablet a day with breakfast then increase to a whole tablet daily. Higher doses can be used. If sedation is required fluvoxamine is more sedating.
  
  
• Explain to the patient:
  • Medication must be taken every day.
  • Improvement will build over 2-3 weeks.
  • Mild side effects may occur but usually fade in 7-10 days.
  • Check with the doctor before stopping medication.
  • Continue antidepressant at least 12 months after symptoms improve, longer if the depression is recurrent.

Specialist Consultation

• Consider consultation if the patient shows:
  • significant risk of suicide or danger to others
  • psychotic symptoms
  • persistence of significant depression following the above treatment.
• More intensive psychotherapies (e.g. cognitive therapy, interpersonal therapy) may be useful for acute treatment and relapse prevention.

What a doctor might say to a person with a depressive disorder