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Mental Health & Substance Use

Depression

A common mood disorder characterized by persistent low mood, loss of interest or pleasure in activities, and reduced energy, leading to impaired functioning.

Also known as: Major Depressive Disorder, Clinical Depression, Unipolar Depression

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Referral and warning signs

When to refer

Refer to specialist (Mental Health specialist/Psychiatrist - HC4/H/RR) if: Severe depression (e.g., with psychotic features, severe functional impairment, high suicide risk). Treatment resistance (failure to respond to adequate trial of 1-2 antidepressants). Diagnostic uncertainty (rule out bipolar). History of mania (indicates bipolar disorder). Co-occurring complex conditions (e.g., severe substance use, personality disorder). Depression in children, adolescents, or pregnant women.

Red flags

  • Active suicidal ideation with plan and intent
  • Psychotic symptoms (delusions, hallucinations)
  • Severe functional impairment (unable to care for self)
  • Catatonia or severe psychomotor retardation/agitation
  • Refusal to eat or drink
  • Symptoms suggestive of bipolar mania/hypomania

Signs and symptoms

  • Core Symptoms (at least 2 present most days for at least 2 weeks):
  • - Persistent low mood (sadness, emptiness, hopelessness).
  • - Loss of interest or pleasure (anhedonia) in normally enjoyable activities.
  • - Lack of energy, fatigue, easily tired.
  • Other Common Symptoms:
  • - Difficulty concentrating, reduced attention, indecisiveness.
  • - Reduced self-esteem and self-confidence.
  • - Feelings of guilt and worthlessness.
  • - Bleak and pessimistic view of the future.
  • - Disturbed sleep (insomnia or hypersomnia).
  • - Changes in appetite and weight (increase or decrease).
  • - Reduced libido.
  • - Multiple body pains or other medically unexplained somatic symptoms.
  • - Ideas or acts of self-harm or suicide (assess risk!).
  • - In children/adolescents: Irritability may be prominent mood, school phobia, truancy, poor academic performance, substance abuse.

Risk factors

  • Biological factors (neurotransmitter imbalance)
  • Genetic predisposition / Family history
  • Environmental factors (stressful life events, loss, trauma, abuse, social isolation, poverty).
  • Chronic physical illness (e.g., HIV, TB, cancer, heart disease, chronic pain).
  • Other mental health conditions (e.g., anxiety disorders, substance use disorders).
  • Certain medications.
  • Postpartum period.

Diagnosis

Clinical assessment

Diagnosis based on clinical interview assessing presence, duration, and severity of characteristic symptoms and functional impairment. Requires symptoms present for at least 2 weeks. Assess for history of mania/hypomania (to rule out bipolar disorder). Assess for psychotic features. Assess suicide risk. Screen for co-occurring physical conditions and substance use.

Investigations

  • Usually diagnosed clinically.
  • Medical, social, personal history including bereavement/loss assessment.
  • Consider investigations to rule out organic causes mimicking depression: Thyroid function tests (hypothyroidism), CBC (anemia), HIV test, screening for other chronic illnesses based on presentation.

Diagnostic criteria

Based on diagnostic criteria (e.g., ICD, DSM) requiring a certain number of core and other symptoms present for at least 2 weeks causing significant distress or functional impairment. Rule out bipolar disorder, substance-induced mood disorder, mood disorder due to another medical condition, and normal bereavement.

Management

Non-pharmacological management

  • First line for mild depression:
  • - Psychoeducation (patient and family counselling).
  • - Addressing current stressors (problem-solving, support).
  • - Reactivating social networks and support.
  • - Structured physical activity / exercise.
  • - Regular follow-up.
  • Psychotherapy (if available, effective for mild-moderate): Cognitive Behavioural Therapy (CBT), Interpersonal Therapy (IPT), Behavioural Activation.
  • Bereavement Counselling: Provide support, do not use drugs/psychotherapy as first line for normal grief.

Pharmacological treatment

  • Antidepressants (Consider for moderate-severe depression or mild depression unresponsive to non-pharmacological approaches):
  • - SSRIs (Selective Serotonin Reuptake Inhibitors) - Often first line:
  • - Fluoxetine: 20mg daily AM (start 10mg in elderly). Increase to 40mg after 4-6 weeks if needed.
  • - Sertraline: 50mg daily (preferred if on other meds due to low interactions, safe in breastfeeding). Increase by 25-50mg increments weekly if needed (max 200mg/d).
  • - Escitalopram: 10mg daily, may increase to 20mg daily.
  • - TCAs (Tricyclic Antidepressants):
  • - Amitriptyline: 50mg nocte initially, increase by 25mg weekly aiming for 100-150mg (divided or single PM dose). Useful if co-existing anxiety/insomnia. Avoid in adolescents, elderly, heart disease, high suicide risk due to overdose toxicity.
  • - SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors):
  • - Venlafaxine: Start 37.5mg daily, increase to 75mg daily (divided doses), maintenance 75-225mg daily (max 375mg). Useful for comorbid anxiety.
  • - Other:
  • - Bupropion: 150mg daily, titrate up to 450mg/day. Useful if comorbid nicotine dependence, less sexual side effects.
  • General Principles: Choose based on side effect profile, comorbidities, availability, cost. Takes 2-4 weeks for initial effect, 4-8 weeks for full effect. Continue treatment for at least 9-12 months after remission to prevent relapse. Taper dose slowly over at least 4 weeks when discontinuing to avoid withdrawal symptoms.
  • Caution: DO NOT use antidepressants in children <12 years. Use ONLY under specialist supervision in adolescents. SSRIs can trigger mania in undiagnosed bipolar disorder. Refer pregnant women to specialist.
  • Follow specific Ugandan treatment algorithms/guidelines.

Monitoring

Monitor symptoms (mood, interest, energy, sleep, appetite, suicidal ideation) regularly (e.g., every 1-2 weeks initially, then monthly). Monitor functional improvement. Monitor for side effects (e.g., GI upset, headache, sexual dysfunction with SSRIs; sedation, dry mouth, constipation, cardiotoxicity with TCAs). Assess adherence. Monitor for emergence of mania/hypomania. Assess suicide risk regularly.

Complications

  • Suicide / Self-harm
  • Impaired social and occupational functioning
  • Substance abuse
  • Worsening of co-existing physical health conditions
  • Increased risk of cardiovascular disease
  • Reduced quality of life

Prevention

  • Stress management skills.
  • Building strong social support networks.
  • Early recognition and treatment of mild symptoms.
  • Addressing underlying risk factors (social determinants, chronic illness).
  • Maintaining healthy lifestyle.

Patient education

  • Explain depression as a medical illness, not a sign of weakness.
  • Reassure that treatment is effective.
  • Explain treatment options (psychosocial, medication).
  • If starting medication, explain it takes time to work (weeks), potential side effects, and importance of adherence (not stopping abruptly).
  • Discuss importance of follow-up.
  • Encourage engagement in pleasant activities and social support.
  • Provide information on managing suicidal thoughts (safety plan, emergency contacts).

Uganda-specific notes

Depression often presents with somatic complaints (multiple body pains). Stigma surrounding mental illness is significant. Assess for co-morbidities like HIV, TB. Assess for social stressors. Psychosocial interventions are crucial. Fluoxetine and Amitriptyline are commonly available antidepressants.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 9, Section 9.2.2

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