Risk of harm to self

Psychotic symptoms

Danger to others

Life threatening drug reaction

For patients with MDD of mild severity, the treating doctor may choose to start antidepressant medication.

Patients who are managed without medication may be offered other means of managing their depression.

Patients should be closely monitored, and given a follow-up appointment within 3 weeks.

In patients who have a past history of moderate to severe depression, who now present with mild depression, consider prescribing antidepressants as an initial measure.

SSRIs should be considered as first line antidepressants.

Consider switching antidepressants if there is no response after 2 month of an adequate dose of antidepressant.

If there is partial response, consider continuing on the same medication for another 2 weeks before deciding to switch antidepressants.

If a decision to switch antidepressant is made, a combination therapy should be chosen.

Examples of SSRIs are escitalopram, sertraline and fluoxetine.

The starting dose of sertraline is 50 mg/day and the usual dose range is 50–200 mg/day.

The main adverse effects includes GI symptoms, rash, insomnia and sexual dysfunction.

The maximum dose range of fluvoxamine is 500 mg/day.

Examples of tricyclics and tetracyclics are clomipramine, maprotiline and tianeptine.

Amitriptyline can cause tachycardia/arrhythmia.

SNRIs such as Venlafaxine can cause insomnia, dry mouth, somnolence and dizziness.

Moclobemide can cause increased increased appetite and weight gain.

Benzodiazepines have a specific antidepressant effect and experts believe that the depressive state can be improved by benzodiazepines alone.

Prescribing benzodiazepines as an adjunct to antidepressants proved to show a better response than the antidepressant alone group

Benzodiazepines should not be prescribed for more than 2-4 weeks

The major problem in benzodiazepines usage is dependence.

ECT is found to be superior to certain antidepressants in the short term but its effects are short-lived.

ECT is recommended if there is a life-threatening condition such as refusal to eat or high suicide risk due to the depressive illness.

ECT has the risk of causing structural brain damage.

ECT is more effective in psychotic depression.

When considering psychological interventions in moderate and severe MDD, the intervention of choice is CBT.

For moderate and severe depressive disorder, the duration of psychological interventions should be in the range of 16 to 20 sessions over 12 months.

When patients present with severe depressive disorder, a combination of antidepressants and CBT should be considered.

For depressed patients with complex co-morbidities, consider giving brief psychodynamic psychotherapy.

If there has been little response after an adequate trial of one antidepressant, consider switching to another antidepressant from a different class.

Lithium augmentation may be considered in treatment resistant depression.

ECT is not recommended in treatment resistant depression due to the severe side effects.

For patients with treatment resistant depression, augmentation with benzodiazepine is also recommended.