The following document was written by Dr Satvir Singh FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry) Kent & Medway NHS and Social Care Partnership Trust Canterbury, Kent in Dec 2007.
You may use the information here for personal use but if you intend to publish or present it, you must clearly credit the author and
This site is not intended to be used by people who are not medically trained. Anyone using this site does so at their own risk and he/she assumes any and all liability. ALWAYS ASK YOUR SENIOR IF YOU ARE UNSURE ABOUT A PROCEDURE. NEVER CONDUCT A PROCEDURE YOU ARE UNSURE ABOUT.



Depression is a common disorder and 1:5 individuals may experience it in their lifetime. It is twice as prevalent in women as in men. Most commonly, it presents between the ages of 20 to 50 years of age, but children as well as older persons also present with mild to severe symptoms of depression. Suicide rate in depression is up to 4 times higher than any other mental health disorders, and 20-30 times higher than the suicide rate in general population.

Recognition of severe depression is quite easy but not so easy in cases of mild depression. Furthermore, it is a little difficult to differentiate between a normal emotional reaction to a given day to day-to-day life events such as social and financial difficulties as compared to a true depressive illness requiring medical attention.

Ideally, an initial thorough work-up as outlined in History Taking in Psychiatry – 1, 2 and 3 will help clinicians to recognise and diagnose almost all cases of depression. If for some reason one is unable to spend the required time with the patient during the first consultation, it is always useful to make another follow-up appointment within a few days or, if necessary, the same day so that you are able to assess and plan the management carefully than rush through and fail to recognise the main concerns of the patient.

It pays to remember that initial time spent with a patient during the first consultation is positively correlated with better outcome and overall patient compliance with the treatment and satisfaction.

A brief physical examination and essential haematological and biochemistry investigations not only give you the patient’s current base line physical health status but also exclude some common physical disorders, which may present with symptoms of depression. In older persons, always exclude the possibility of malignancy, diabetes, thyroid, liver and renal dysfunctions and related disorders. A routine PSA in all men aged 50 years or over, is good clinical practice.

Sometimes, the initial symptoms of lethargy, tiredness, inability to cope with day-to-day life stresses, lowered mood, disturbed sleep pattern and change in appetite and weight could well be due to the underlying occult physical pathology such as lung and pancreatic malignancies.

In case the patient does not respond to the standard methods of treatment for depression, it is advisable to re-evaluate thoroughly his/her physical state.

Diagnosis of Depression

Most psychiatric disorders present with psychological, physical (biological) and behavioural (social) signs and symptoms and it is always useful to recognise these as such in different categories. It also helps to understand the probable aetiological factors as well as management of the patient.

Following are the main psychological, physical and behavioural symptoms of depression:

Psychological Symptoms

Physical Symptoms

Behavioural Symptoms

In clinical practice, mild to moderate severity of depression would have significant number of psychological symptoms, while in severe depression, there will be a lot more physical symptoms plus depressive delusions such as delusions of sin, poverty, malignancy & infection and other irrational fears and wrong-doings in life (overvalued ideation).

As per ICD-10, the following criteria are applied to differentiate between mild, moderate and severe depression:

List A - Symptoms duration, at least of two weeks.

List B

Mild Depression

Moderate Depression

Severe Depression

However, in clinical practice, it is the change in level of functioning at social, professional and family level should remain a guiding principle of severity besides the above.

It is also useful for the patient as well as the treating doctor to make use of some “easy to apply” questionnaires, which not only help in monitoring the progress of the patient but also to gain insight in the various symptoms and behavioural changes that one can expect in depressive illness:

  1. The Hospital Anxiety & Depression Scale – Zigmond & Smaith, 1983

  2. Beck Depression Inventory, Aaron T Beck, 1961

  3. 17 item Hamilton Depression Rating Scale (HAM-D), M Hamilton, 1967

  4. Pierce Suicide Intent Scale, for use only after a suicide attempt, 1977

Treatment Options

Once the diagnosis of depression has been established, the next step is to decide whether the patient can be treated as an out-patient by you, a GP or he/she needs to be referred to the specialist services. The decision is usually based on the severity of symptoms and the views of the patient and his/her main caregiver.

Patients with severe depression and psychotic features, where they may be at risk to themselves or others, are best referred to the local mental health services for further assessment and treatment. Usually such patients will need in-patient treatment and occasionally they may require admission under the Mental Health Act, 1983.

The patients with mild to moderate depression are normally managed as out-patients by GPs and/or the community mental health team staff.

There are essential 4 key steps in managing depression in the community:

Step 1 Diagnosis and Investigations

Step 2 Briefing and Involvement of other key members of family/partner

Step 3 Non-pharmacological treatment of Depression

Step 4 Pharmacological treatment of Depression

Step 1

The first step in management of depression should constitute the following:

The first consultation should end with the patient being reassured and better informed. The patient is also advised to bring along their key caregiver/partner to the next consultation.

Step 2

The second consultation should include the following:
The theory of IPT is based on the principle that the symptoms of depression are the result of relationship difficulties and resolving these difficulties, as well as attitudes to self and others will improve most symptoms of mild and moderate severity.

Effectively, by this stage, you have established the clinical diagnosis of depression and its severity. You have also excluded any underlying occult physical pathology responsible for the patient’s symptoms. You have explained, informed and reassured the patient about the presenting symptoms and that they are treatable. Above all, you have involved the patient’s main caregiver/partner in the management of your patient. Also, without you realising, you have developed a “Therapeutic Alliance,” trust and confidence with your patient as well as with the caregiver/partner.

Outline your plans to treat the patient, which should include details about the following:
  1. Non-pharmacological treatment

  2. Roles and responsibilities of the patient

  3. The pharmacological treatment

  4. Follow up arrangements


With regard to the non-pharmacological treatment of depression, I suggest the following:


Before prescribing any medication, it is useful to inform the patient of the following:
Following is a brief summary of antidepressants that are currently available in the UK market and some guidelines on how to choose the most appropriate:

British National Formulary (BNF 2007) lists currently available 26 antidepressants under four broad categories:

Tricyclic Antidepressants

Related Antidepressants

Monoamine-Oxidase Inhibitors (MAOIs)

Reversible MAOIs

Selective Serotonin Reuptake Inhibitors (SSRIs)

Other Antidepressants

In General Practice almost all patients with mild to moderate depressive illness without active suicidal intent and psychotic symptoms can be managed with only four of the above listed antidepressants. It is better to learn well about a few antidepressants rather than trying different ones with limited experience and knowledge.

  1. Citalopram

  2. Fluoxetine

  3. Mirtazapine

  4. Duloxetine


Before writing a prescription, ask these questions again:
  1. Can the patient be treated with non-pharmacological methods of treatment? (Mild Depression)

  2. Can the patient be safely treated as an out-patient? (Mild to Moderate Depression without active suicidal intent and good social support)

  3. Should the patient be referred to the community and/or in-patient mental health services because he/she is severely depressed with active suicidal intent and/or psychotic symptoms, Bipolar Mood Disorder, poor compliance and absence of social support network, depression with other psychiatric disorders such as schizophrenia, drug and alcohol abuse and dementia.

Also, consider the following:

The following would further help to decide which antidepressant to choose:


If after 4-6 weeks, there is no improvement then consider adding a small dose of SSRIs.

Consider prescribing Citalopram 10 mg daily after breakfast gradually increasing to 20 mg daily after 3-4 days. By starting with a small dose of 10 mg you avoid the side effects such as nausea, vomiting, dyspepsia, abdominal pain, diarrhoea, increased anxiety, headaches, insomnia, tremor and dizziness.

Continue the antidepressant for six months after full recovery in case of first episode. As the symptoms improve, the patient should be encouraged to come off the night sedation.


In cases of depression of moderate severity, consider starting the antidepressant as the first line treatment with advice regarding the various non-pharmacological treatment options and introduce them as and when practically possible and the patient is ready to try them out.

The patient will start showing some improvement within 2-3 weeks especially in his/her symptoms of insomnia, anxiety and energy level. Thereafter improvement will be noticed in mood, motivation and confidence level.

Continue the antidepressant for 6-12 months after full recovery and thereafter, you may consider reducing the dose and gradually withdrawing it over a period of 3-6 months.

In case of no response to antidepressant after six weeks, consider the following:

If, say after another 3 weeks there is still no response, then consider switching to another antidepressant.


Here we have the choices of four other antidepressants


If the patient is significantly troubled by the symptoms of Bulimia and/or Obsessive Compulsive Disorder, then consider replacing Citalopram with Fluoxetine 20 mg daily increasing 40-60 mg daily over a period of 4-6 weeks.


If the patient is significantly troubled by the symptoms of generalised or specific social phobic anxiety with or without panic attacks, then consider using Escitalopram in doses of 5 mg to a maximum of 20 mg daily after breakfast.


If the patient is significantly troubled by poor sleep pattern then consider the use of Mirtazapine, starting with 15 mg nocte and gradually increasing to a maximum of 45 mg nocte.

Look out for increase in appetite and weight gain, excessive sedation, oedema and less commonly, headaches, dizziness, arthralgia, akathesia, rash and reversible agranulocytosis.


Duloxetine is classified as Serotonin and Noradrenaline Reuptake Inhibitor (SNRI), similar to Venlafaxine but without any serious cardiac side effects. It is about 5 times more potent in inhibiting the reuptake of serotonin than that of noradrenaline.

If the patient is presenting with significant symptoms of lethargy, low energy level, lack of motivation, withdrawn with lowered mood, then consider using Duloxetine 30 mg nocte increasing to 60 mg nocte.

Duloxetine does not have the side effects of sexual dysfunction as is in the case of most SSRIs.

Watch out for the side effects of nausea, vomiting, dyspepsia, diarrhoea, insomnia, headaches and dizziness.

A combination of two antidepressants could be safely considered in General Practice. The only combination that could be considered would be Citalopram and Mirtazapine. When the patient has initially responded to Citalopram but has been troubled by major sleep disorders, a combination of Citalopram 10-20 mg mane and Mirtazapine 15-30 mg nocte may be considered.

If there is no response to at least two different antidepressants, you should consider referring the patient to the local mental health services.

Treatment of severe depression with active suicidal intent and psychotic features should be dealt with by a specialist team as an in-patient and will be described elsewhere.

Dr Satvir Singh
FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS
Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry)
Kent & Medway NHS and Social Care Partnership Trust
Canterbury, Kent


1. ICD-10, WHO, 1992
2. DSM-IV, AMA, 1994
3. Oxford Handbook of Psychiatry, Semple D, et al, 2005
4. Core Psychiatry, Second Edition, Wright P, et al, 2005
5. Companion to Psychiatric Studies, Eve C Johnstone, et al, 1998
6. Shorter Oxford Textbook of Psychiatry, Fifth Edition, M Gelder et al, 2006
7. MIMMS Handbook of Psychiatry, 3rd Edition, Janssen Cilang, 2006
8. BNF, Sept 2007
9. Stress, Anxiety and Depression, Burrows G, et al, 1999
10. The Maudsley, Prescribing Guidelines, 9th Edition, Taylor D, et al


The authors of this document have attempted to provide information that is medically sound and up-to-date. The authors nor cannot take any reponsibility for the accuracy or completeness of this article. The reader should confirm the statements made in this website before using the information outside this website.