Depression
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Session outline
• Introduction to depression
• Assessment of depression
• Management of depression
• Follow-up
• Review
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Activity 1: Person’s story followed
by group discussion
• Present the first person account of a
person living with depression.
• First thoughts.
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Local descriptions of depression
• What are the local terms/names for
depression?
• How are people with depression
treated and perceived by the local
community?
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Core symptoms of depression
• Persistent depressed mood.
• Markedly diminished interest in or
pleasure from activities.
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Common presentations of depression
• Multiple persistent • Significant change in
physical symptoms with appetite or weight
no clear cause (weight gain or loss)
• Low energy • Beliefs of worthlessness
• Fatigue • Excessive guilt
• Sleep problems (sleeping
too much or too little) • Indecisiveness
• Anxiety • Restlessness/agitation
• Hopelessness
• Suicidal thoughts and acts
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Contributing factors
Biological
Social Psychological
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Identifying depression
The length of time that a person
experiences the symptoms is one of the
distinctions between depression and
general low mood.
How long do you think symptoms should
be present?
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Identifying depression
• Depression means that there is a considerable
impairment in a person’s ability to function in daily
life.
• Some people may experience a persistent
depressed mood but they are able to continue
functioning in daily life. Therefore, their symptoms
do not amount to depression and can be managed
via the Module: Other significant mental health
complaints in mhGAP-IG Version 2.0.
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Socioeconomic impact
• High unemployment
High prevalence rates
• Worsening living conditions
• 322 million people
worldwide
• 4.4% in the community
• 10–20% in primary care Disability and mortality
attenders • Major cause of disability
• 10% women who have given • High suicide rates
Depression:
birth
A public health
priority
Impact on families Correlations with other
• Infant growth physical health
• Family relationships
conditions
• Noncommunicable diseases
• Child rearing
• Communicable diseases
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Average prevalence of depression in people
with physical diseases (70 countries)
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Activity 2: Video demonstration:
Assessment
• Show the mhGAP-IG depression
assessment video.
https://www.youtube.com/watch?v=
hgNAySuIsjY&index=1&list=PLU4iesk
Oli8GicaEnDweSQ6-yaGxhes5v
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Process of assessment in the video
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Sarah’s case
• Sarah is 23 years old and has a baby at
home.
• What else do we want to know:
o Is she breastfeeding?
o Is she pregnant?
o Is the baby developing well?
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Consider physical conditions
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Physical conditions that
resemble depression
Condition Symptoms
• Anaemia • Tiredness, loss of energy, problems
sleeping, physical aches and pains,
problems concentrating.
• Malnutrition • Tiredness, loss of energy, loss of
appetite, lack of interest in food and
drinks, poor concentration, low mood,
feeling weak.
• Tiredness, muscle aches and feeling
• Hypothyroidism weak, changes in appetite (weight gain),
low mood, problems with memory and
concentration (slowed thinking), loss of
libido, loss of energy.
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Grief
• Low mood, anxiety, fear, • Social withdrawal, loss
guilt, self-blame, of interest, restlessness,
irritability, loneliness, agitation.
crying. • Loss of appetite,
• Negative thinking, problems sleeping, loss
rumination, low self- of appetite/appetite
esteem, hopelessness, gain, physical aches and
pessimism about the pains, tiredness, loss of
future. energy.
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Sarah’s case
• Did the health-care provider assess if Sarah had
a history of mania?
• What questions could they have used to explore
whether she had experienced any of these
symptoms?
• Did the health-care provider assess if Sarah had
experienced a major loss in the past six months?
If so what questions could have been asked?
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Assess for imminent risk of suicide
• Talking about self-harm/suicide is
ESSENTIAL.
• Talking about self-harm/suicide DOES NOT
increase the risk that the person will
commit self-harm/suicide.
• If there is a risk of self-harm/suicide then
GO IMMEDIATELY TO MODULE: SELF-
HARM/SUCIDE IN THE mhGAP-IG AND
FOLLOW THE STEPS TO MANAGE SELF-
HARM/SUICIDE.
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Activity 3: Depression role play 1
Assessment
A person with fatigue, poor sleep and
weight loss comes to see a health-care
provider.
Practise using the mhGAP-IG to assess a
person for possible depression.
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Promote functioning in daily activities
Brief psychological
Reduce stress and treatment for
strengthen social depression
support
Psychoeducation Pharmacology
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Treatment plans should include:
• Presenting problem: • Action plan: Record the
What are the person’s steps, goals and
health and social needs? behaviours that need to
happen, who will do them
• Which interventions best and when?
meet the person’s health • Manage risks (plans for
and social needs? what people can do in a
crisis).
• Involve the person and
the carers to ensure
ownership of the
treatment plan.
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Activity 4: Management of depression –
which interventions?
• This is an opportunity to familiarize yourself with
the psychosocial interventions for depression.
• In your groups identify the:
• Key elements of a particular psychosocial
intervention.
• Barriers and risks of using that interventions.
• Identify solutions to those barriers and risks.
Present the information in the form of a poster. Be as
creative as you wish.
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When to refer
Consider a referral to a mental Consider a referral to a
health specialist (where hospital:
available): • If a person is non-
• If a person with depression responsive to treatment.
shows any signs of psychotic • If a person shows serious
symptoms (e.g. side-effects of any
hallucinations and pharmacological
delusions). interventions.
• If the person presents with • If a person needs further
bipolar disorder. treatment for any comorbid
• If the person is pregnant or physical condition.
a breastfeeding woman. • There is a risk of self-
• In the cases of people with harm/suicide.
self-harm/suicide.
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Link with other sectors
• Linking people with other sectors ensures:
• That the person receives a comprehensive
package of care.
• It fulfils parts of the psychosocial
interventions, e.g. in order to promote
functioning in daily activities and community
life. If the person has identified that they
would like to return to their studies and/or
start a livelihood activity, it is important to link
them to livelihood organizations.
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Brief psychological treatments
• As first-line therapy, health-care providers may
select psychological treatments and/or
antidepressant medication.
• When deciding, they should keep in mind the:
o Possible adverse effects of antidepressant
medication.
o The ability to deliver either intervention (in terms
of expertise, and/or treatment availability).
o Individual preferences of the person.
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Group interpersonal
therapy (IPT)
• Assumes that depression is
triggered by interpersonal
difficulties in one or more
problem area:
o grief
o interpersonal disputes
o role transitions
o Interpersonal deficits.
• By understanding the
relationship between
interpersonal events and stress,
and by helping the person
improve their skills to handle
these events, we can help the
person recover.
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Multi-component
behavioural
treatment (PM+)
• Problem-solving
counselling
• Managing stress (slow
breathing)
• Behavioural activation
• Strengthening social
supports
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Thinking healthy –
cognitive behavioural
therapy for perinatal
depression
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Activity 5: Video demonstration:
Managing depression
You will now see a video which shows the health-care
provider managing Sarah’s depression. Whilst
watching the video think about:
1. How did the health-care provider explain the
treatment options available?
2. Did the health-care provider explain the risks and
benefits of different treatment interventions?
https://www.youtube.com/watch?v=hdR8cyx2iYU&lis
t=PLU4ieskOli8GicaEnDweSQ6-yaGxhes5v&index=2
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Pharmacological interventions:
When NOT to prescribe
• Do not prescribe an • Do not prescribe an
antidepressant if there is no antidepressant if the person
is pregnant/breastfeeding.
depression. For example: As first-line treatment, offer
o When the symptoms do not psychosocial intervention
last two weeks and/or do first.
not involve impaired • Do not prescribe if the child
is younger than 12.
functioning).
• Do not prescribe to
o If the symptoms are part of adolescents aged 12–18 as
a normal grief reaction. first-line treatment. Offer
psychosocial interventions
o If the symptoms are due to first.
a physical cause.
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Precautions for
tricyclic antidepressants (TCAs)
Avoid use in:
• The elderly, people with
cardiovascular disease and people
with dementia.
• People with ideas, plans or previous
acts of self-harm or suicide – to
minimize the risk of overdosing.
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Choosing an appropriate antidepressant
Quiz time
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Q&A
Which antidepressant would you recommend
for adolescents 12 years and older?
Consider fluoxetine (but no other selective serotonin
reuptake inhibitors [SSRIs] or TCAs) only when symptoms
persist or worsen despite psychosocial interventions.
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Q&A
Which antidepressant would you recommend
for children under the age of 12?
NO antidepressants. Use only psychosocial techniques.
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Q&A
Which antidepressant would you recommend
for pregnant or breastfeeding women?
Avoid antidepressants if possible. Consider antidepressants
at the lowest effective dose if there is no response to the
psychosocial interventions. If the woman is breastfeeding,
avoid fluoxetine. Consult a specialist, if available.
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Q&A
In what groups should you avoid and/or not prescribe
amitriptyline?
Avoid in elderly people.
Do not prescribe it to people with cardiovascular disease.
Like all antidepressants, it should not be prescribed to children,
and be avoided in pregnant women.
Avoid in people with thoughts or plans of suicide (SSRIs are the
first choice). 52
Q&A
How should you prescribe fluoxetine to someone
who has an imminent risk of suicide?
If there is an imminent risk of self-harm or suicide, give only
a limited supply of antidepressants (e.g. one week’s supply at
a time).
Ask carers to monitor medicines and to follow-up frequently
to prevent medication overdose.
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Activity 6: Depression role play 2:
Psychosocial interventions
A 27-year-old was identified as having depression one week ago. One year
ago he was employed in a busy bank in line for a promotion and engaged
to be married.
Then his fiancée left him, unexpectedly, for another person. He felt that
the stress of work and started to feel very anxious and worried all the
time. He stopped being able to sleep or eat well. He felt more and more
sad and depressed. His personality started to change; he was irritable,
forgetful, socially isolated and unable to spend time with family and
friends as he felt ashamed and guilty. He had no work and no income and
blamed himself for everything that had happened in his life.
• Use the mhGAP-IG to develop a treatment plan using psychosocial
interventions.
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Possible presentations at follow-up
At follow up you may see people:
1. Improving (actively engaging with
management interventions and their
symptoms are improving).
2. Remaining the same (actively engaged in
management interventions but their
symptoms are remining the same) or
deteriorating (the symptoms are deteriorating
and the person is feeling worse).
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Activity 7: Video demonstration:
Follow-up
Show the final video of Sarah returning for a follow-
up appointment with the health-care provider.
1. Which of Sarah’s symptoms had improved at
follow-up?
2. What new information did the health-care
provider learn?
3. Why was that information important?
https://www.youtube.com/watch?v=F3MKvTxQvF4&l
ist=PLU4ieskOli8GicaEnDweSQ6-yaGxhes5v&index=3
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Monitoring people on antidepressants
It is expected that people will have a positive
response, but there are some results that will
require action – if the person shows:
• symptoms of mania
• inadequate response
• no response.
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What do you do when symptoms worsen
or do not improve after four to six weeks
(inadequate response)?
Take three important steps before increasing the dose:
1. Ensure that the assessment is correct.
2. Ensure that the person is taking the medication
as prescribed.
3. Ensure that the dose is adequate.
If there is no improvement after four to six weeks at
maximum dose, consult a specialist.
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When and how to stop an antidepressant
If after 9–12 months of therapy the person reports no
or minimal symptoms:
• Discuss the plan with the person before reducing
the dose.
• Describe early symptoms of relapse.
• Plan routine and emergency follow-up.
• Reduce dose gradually over at least four weeks.
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Antidepressants: Summary
• Time for response to antidepressants four to six weeks.
• Treatment should continue for 9–12 months.
• Taper slowly if ceasing medication.
• Do not prescribe antidepressants to:
o A functioning person.
o Someone recently bereaved.
o Children (under 12) and pregnant/breastfeeding
women.
• Avoid TCAs if:
o The person is elderly, has dementia or has
cardiovascular disease.
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Review
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