High risk groups 1–6

  • Permanent aged care facility residents
  • Physically inactive
  • Overweight and obese
  • Harmful levels of alcohol consumption
  • Aboriginal, Torres Strait Islander and culturally and linguistically diverse groups
  • Sexual minorities and gender diverse groups
  • Socioeconomically disadvantaged and homelessness
  • Prolonged grief and emotional pain
  • Exposure to emotional neglect, or sexual and physical abuse
  • Childhood trauma
  • People with disabilities and life-limiting injuries
  • Post-partum women until child is 3 years of age

Considerations in pregnancy 7–9

  • Suspect depression in both the antenatal and postnatal periods
  • Assess risks and benefits of antidepressants while pregnant and breastfeeding
  • Offer to screen using the Edinburgh Postnatal Depression Scale (EPDS) or Kimberley Mum’s Mood Scale (KMMS) (Resource 1.):
    • early in pregnancy and at least once in later pregnancy
    • 6–12 weeks after birth and as required over the following months
    • monitor those who score 10–12 every 2–4 weeks
    • refer all patients to mental health services who answer ‘yes’ to question 10 or score > 13

Urgent referral

  • Refer to Mental health services or to the Primary Clinical Care Manual for:
    • protracted or severe depression
    • atypical features
    • psychotic episodes
    • high risk of suicide or self-harm
  • Lifeline 1300 131 114 (local call)
  • Kids Helpline 1800 55 1800 (free call)

1. What is depression? 1–9

  • A low or irritable mood, resulting in a loss of enjoyment or pleasure and impairing a person’s ability to function. See Table 1.
  • Can be long lasting or recurrent
  • Common and treatable but can result in disability or death if left untreated
  • Recurrence is common even when treated appropriately. Each episode increases the risk of future episodes
  • Depression varies for each person and may change over time
  • Table 1. outlines key signs and symptoms of depression
  • Types of depression include:
    • Major depression – occurs in episodes. Must meet the criteria in Table 1. for a diagnosis to be considered
    • Dysthymia – a milder version with fewer physical symptoms than major depression but often lasts longer. It is defined by emotional symptoms such as dark or gloomy thoughts
    • Psychotic depression – extreme thoughts of profound despair, guilt and self-loathing, strongly-held false beliefs, agitation, hallucinations and severe social withdrawal
    • Bipolar disorder – symptoms of depression and mania at different times. Mania is a period of elevated mood with symptoms such as rapid speech, reduced need for sleep and excessive behaviours like gambling, promiscuity and shopping sprees
    • Perinatal depression – experienced by 10% of prenatal and 16% of postnatal women. Most prevalent 6 months postnatally. Depression before baby’s 3rd birthday is considered postnatal depression

2. Diagnosis of depression 1,6,8

  • Diagnosis of depression involves 2 clinical processes:
    • initial assessment:
      • identifying a patient’s strengths to guide management e.g. their place in the family, school or employment and their local environment
      • psychosocial assessment with validated screening tools. See Resource 1.
      • identifying distress e.g. grief, conflict or stress from developmental, familial or sociocultural events
      • reports from family, carers or others of changes to symptoms over time
    • exploration of depressive symptoms:
      • symptoms consistent with depression diagnostic criteria. See Table 1.
      • exclusion of other depressive symptom causes e.g. other mental health conditions, substance use or comorbidities
      • suicidal and self-harm ideation when symptoms are present
      • categorise severity of depression as:
        • mild – symptoms cause distress with some difficulty carrying out usual activities
        • moderate – several symptoms may be present to a marked degree with considerable difficulty carrying out usual activities
        • severe – symptoms cause considerable distress, agitation or psychomotor retardation with an inability to continue usual activities beyond a minimal extent. Somatic symptoms are prominent and suicide is a particular risk

Table 1. Diagnostic criteria for major depressive disorder 10

  • Any or all observed or reported by self or others
  • Five or more of the following symptoms have been present during the same 2 week period and represent a change from previous functioning and at least one of the symptoms is either dysphoria or anhedonia and:
    • the symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
    • the episode is not attributable to the physiological effects of a substance or another medical condition
    • at least one episode is not explained by schizophrenia or a schizoaffective disorder, a delusional disorder, or another psychotic disorder
    • there has never been a manic episode or a hypomanic episode

Symptoms

Manifestation

Depressed mood (dysphoria)

  • Feels sad, empty, hopeless
  • Most of the day, nearly every day
  • Can be irritable mood in children and adolescents

Loss of interest or pleasure (anhedonia)

  • Markedly reduced interest or pleasure in all, or almost all, activities
  • most of the day, nearly every day

Weight loss or gain

  • Significant weight loss or gain (> 5% change in 1 month) or decrease or increase in appetite nearly every day
  • Failure to make expected weight gains in children

Insomnia or hypersomnia

  • Nearly every day

Psychomotor agitation or retardation

  • Feelings of restlessness or being slowed down
  • Nearly every day

Fatigue or loss of energy

  • Nearly every day

Feelings of worthlessness or excessive or inappropriate
guilt (may be delusional)

  • Not merely self-reproach or guilt about being sick
  • Nearly every day

Diminished ability to think or concentrate, or indecisiveness

  • Nearly every day

Recurrent thoughts of death or suicide

  • Not just fear of dying
  • Suicidal ideation with or without a specific plan or a suicide attempt

3. Management of depression 2,9

  • The goal of managing depression is to avoid relapse or recurrent episodes by:
    • building therapeutic partnerships with the individual and carers by involving them in communication, co-ordination and treatment
    • supporting a dignified, productive and active life
    • identifying and addressing coexisting Anxiety disorders
    • Identifying and addressing suicidal or self-harm ideation. See 3.1 Suicide risk
    • promoting Lifestyle modifications and psychological therapies as first line treatment for mild to moderate depression
  1. Self-harm risk 2,6,7
    • Assessment of self-harm risk is crucial, but can be difficult
    • Table 2. provides a guide to assess self-harm risk at each visit
    • Patients who have the following features should be assessed for suicidal ideation:
      • male
      • Aboriginal and Torres Strait Islander people
      • age < 20 years and > 45 years of age
      • past major depressive episodes
      • previous suicidal attempts
      • drug or substance use
      • loss of rational thinking e.g. psychosis or severe depression
      • loss of a partner, social isolation or community separation (shame)
      • loss of supports, isolation or lack of community connection
      • a suicide plan
      • resources and ability to carry out suicide plan
      • chronic or terminal illnesses
    • Refer to Life Promotion Officers and crisis counselling services. See Resource 2.
    • Provide resources to those who have attempted suicide and their support person. See Resource 3.
  2. Support patient self-management 2,8
    • Provide depression information related resources. See Resource 4. and 5.
    • Discuss the role lifestyle modification, particularly physical activity, has in improving self-esteem and mood
    • Develop a management plan for the course of treatment
    • Encourage women during and after pregnancy to regularly perform a self administered EPDS or KMMS. See Resource 1.
    • Encourage the patient to identify barriers to adequate lifestyle modification and medical adherence and create goals to overcome those barriers. See Engaging our patients
  3. Social-emotional support 1,2
    • Anxiety disorders coexists in up to 50% of those with depression
    • See Social-emotional wellbeing
  4. Carer support 10
    • The burden of caring for someone with depression is a source of depression and stress in its own right
    • Carers may experience isolation and abuse if patient is violent or agitated
    • Ensure carer is supported and engaged in service coordination
    • Provide resources and refer carers to support services to assist with their own needs. See Resource 7.
    • Referral to respite allows carers to have a break and enables patients to stay in their home longer. See Resource 8.

Table 2. Questions to assess self-harm risk 7

Assessment of self-harm risk

  • People who feel like you, sometimes think life is not worth living; have you thought that?
  • Have you been thinking of harming yourself?
  • Are you thinking of suicide?
  • If yes, how often are you having these thoughts?
  • Have you thought about how you would act on these?
  • Is there a plan? (explore the plan; is it feasible? available to the patient? will it succeed?)
  • Have you thought about when you might act on this plan?
  • Are there any things/reasons that stop you from acting on these thoughts?
  • Have you tried to harm yourself in the past?
  • If yes, how many times?
  • When was the most recent time?
  • Do you know anyone who has tried to harm themselves?
  • Have you had a friend who has suicided?
  • Has there been an anniversary of an incident that effected you emotionally? e.g. death of friend or loved one
  • Do you feel safe at the moment?

If a suicide attempt has been made

  • What did you hope would happen as a result of your attempt? (die, end their pain, other?)
  • Do you regret that you did not succeed?
  • Do you still have access to the method used?
  • Did you use alcohol or drugs before the attempt? What did you use?
  • Do you have easy access to a weapon?

Assessment of risk of harm to others

  • Have you thought of hurting anyone else?
  • If yes, have you acted on these thoughts?
  • Have you been involved in any fights recently?
  • If yes, were you using drugs or alcohol at the time?

Added alerts to consider for Aboriginal or Torres Strait Islander people

  • Recent social group bereavement? Suicide? Imprisonment? Conflict?
  • Previous or current trouble with legal issues?

If you suspect your patient is at risk of harm to themselves or others, refer immediately to the Primary Clinical Care Manual

  1. Substance use
    • Identify and manage co-occuring substance use to treat depression effectively
    • Refer patients with co-occurring mental illness and substance use disorder to MHAODs
    • See Alcohol reduction and Smoking cessation
  2. Psychotherapy 2,6,7
    • Psychotherapy is associated with lower relapse rates after two to three years
    • Cognitive behaviour therapy (CBT) and interpersonal psychotherapy (IPT) are considered first line treatment
    • Psychotherapy:
      • can be as effective as antidepressants for mild to moderate depression
      • may provide skills that reduce risk of relapse
      • requires commitment by the person with depression
      • requires referral to an appropriately trained clinician e.g. social worker, mental health worker or psychologist
    • General principles of psychotherapy are to:
      • problem-solve stressors at the time they occur
      • resist thoughts of pessimism and self-criticism and replace them with realistic thoughts
      • practise behavioural activity tasks to improve mood
  3. Relapse and recurrent depression 2,6,7
    • Most presentations will be for a second or subsequent episode of depression
    • Check diagnosis and consider a second opinion
    • Identify barriers to medicine adherence (e.g. nausea or sexual dysfunction) and discuss solutions (e.g. medicine change or counselling)
    • Monitor adequacy of medicines dosage and treatment period
    • Consider second line treatments
    • Reassess the patient’s knowledge, participation and adherence to their treatment regimen for at least 1 year for a first episode and 3 years for recurrent episodes

4. Medicines for depression 2,6,7,9

  • Lifestyle modifications and psychological therapies are first line treatment for mild to moderate depression
  • For patients who benefit from initial antidepressant treatment, continue treatment for 6–12 months to prevent relapse
  • Monitor medicines regularly with special attention to adherence
  • Do not use tricyclic antidepressants to treat major depressive disorder in adolescents
  • Seek specialist advice before initiating medicines in children
Suicide risk is high for young people < 25 years of age on antidepressants.
Monitor closely
  • Flowchart 1. illustrates medicine management of depression
  1. Antidepressant choice 2,7,9
    • When choosing an antidepressant start with any first line medicine. See Table 3.
    • Monitor patient every 2–4 weeks once therapy has been commenced until satisfactory response has been achieved
    • An alternate antidepressant is indicated where there is good adherence but the therapeutic response is poor despite uptitration to maximum dose over 4–8 weeks
    • To reduce the risk of interactions when changing or commencing antidepressants consider their class and an adequate washout period. See Resource 8
    • Inform patients:
      • SSRIs and SNRIs are well tolerated, however side effects are worse initially e.g. nausea, sedation
      • improvement to symptoms should occur 2 weeks after medicine initiation
      • provide Resource 9. to those taking psychotropic medicines

Flowchart 1. Medicine management of depression 7,8,9

Medicine management of depression

Table 3. Medicines for depression 6,9,11,12

First line medicines

Selective serotonin reuptake inhibitors (SSRIs)

  • Side effects include: nausea, diarrhoea, sleep disturbance, orthostatic hypotension, dizziness, hyponatraemia, increased risk of GI bleeding, sedation and weight gain
  • Sexual dysfunction may occur e.g. loss of libido, orgasm and ejaculatory disturbance
  • Sertraline most commonly used in pregnancy
  • Compatible with breastfeeding
  • If drowsiness occurs give in the evening
  • Montior closely in children and adolescents

Fluoxetine 20 mg PO mane up to 60 mg

Fluvoxamine 50 mg PO mane up to 300 mg in divided doses

Escitalopram 10 mg PO mane up to 20 mg. If > 65 years commence 5 mg PO daily up to 10 mg

Paroxetine 20 mg PO mane up to 50 mg. If > 65 years commence 10 mg PO daily up to 40 mg

Sertraline 50 mg PO mane up to 200 mg

Citalopram < 65 years old 20 mg PO mane up to 40 mg; > 65 years old 10 mg PO mane up to 20 mg

Mirtazapine

  • Side effects include increased appetite, weight gain, sedation, weakness, peripheral oedema
  • Not used in children and adolescents

Mirtazapine 15–30 mg PO nocte up to 60 mg

Second line medicines

Serotonin and noradrenaline reuptake inhibitors (SNRIs)

  • Side effects as for SSRIs, plus tachycardia, hypertension
  • Compatible with breastfeeding
  • Not used in children and adolescents

Venlafaxine CR 75 mg PO mane up to 375 mg

Duloxetine 60 mg PO mane up to 120 mg. Reduce dose in renal impairment

Desvenlafaxine CR 50 mg PO mane up to 200 mg. Reduce dose in renal impairment

Third line medicines

  • Under supervision of a psychiatrist for patients with treatment-resistant major depression or those who have previously responded to them well

SSRI/SNRI + Mirtazapine (combination as above)

Tricyclic antidepressants (TCAs)

  • Side effects include: sedation, dry mouth, blurred vision, pupil dilation, decreased lacrimation, constipation, weight gain, orthostatic hypotension, sinus tachycardia, urinary hesitancy or retention, reduced GI motility, anticholinergic delirium (in the elderly and in Parkinson’s disease), impotence, loss of libido, tremor, dizziness, sweating, agitation, insomnia, anxiety, confusion
  • Below has high risk of fatality in overdose. Not used in children or adolescence

Amitriptyline 25–75 mg PO nocte, to target dose of 150 mg (max. 300 mg)

Doxepin 25–75 mg PO nocte, to target dose of 150 mg (max. 300 mg)

Clomipramine 25–75 mg PO nocte, to target dose of 150 mg (max. 300 mg)

Selective, reversible MAO-A inhibitors

  • Not used in children and adolescence

5. Cycle of care

Cycle of care summary for depression

Action

Dx

Frequency

Full physical health check

12 mthly

TFT, FBC, LFTs, UEC, glucose, syphilis serology, fasting lipids

Dependent on any underlying medical condition and medicine use

BP

At 1 mth, then every 3–6 mths based on medicines

Height, weight and BMI

At 1 mth, then every 6 mths

Waist circumference

Electrocardiogram

Perform if condition changes

Self harm risk

At each review

Substance use

Screen every 6 months

Medicine review

Wkly for 6 wks then at 6 mths and 12 mths. May need to be more often based on clinical presentation

Mental state examination (MSE)

Lifestyle modifications

Mental Health Worker review

Wkly until stable

Mental health team (MHAODs)

As required

MO/NP

Wkly until stable then with medicine review

Psychiatrist

For moderate/severe/unresponsive depression or immediately if self-harm is identified

6. References

7. Resources

  1. The Edinburgh Postnatal Depression Scale – Kimberley Mum’s Mood Scale (KMMS)
  2. Life promotion and counselling support is available from: Suicide Call Back Service or BluePage or beyondblue or the Black Dog Institute or Lifeline 1300 131 114 (local call) or Kids Helpline 1800 55 1800 (free call) or Head to Health or e-mental health in practice
  3. Finding your way back – resources for support after a suicide attempt
  4. Depression related resources are available from BluePage or beyondblue or the Black Dog Institute
  5. For perinatal depression related resources see PANDA or PANDA’S national perinatal mental health helpline 1300 726 306 or Queensland Centre for Perinatal and Infant Mental Health’s promotion and prevention resources
  6. Carers Queensland
  7. Respite care service via myagedcare
  8. For antidepressant washout periods see the Australian Medicines Handbook or the Therapeutic Guidelines
  9. Mental health medicine information for consumers and carers

Last updated: September 2024

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