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23.5 Major Depressive Disorder

Table of Contents

It is a mood disorder characterised by at least 2 weeks of depressed mood and/or diminished interest and pleasure in activities. It is associated with impairment in level of functioning in different areas including social and occupational.

Diagnostic Criteria

Psychological symptoms

  • Depressed mood
  • Feeling of worthlessness
  • Guilt
  • Diminished concentration
  • Thoughts of death and suicide

Somatic symptoms

  • Change in appetite
  • Sleep disturbances
  • Agitation
  • Retardation
  • Loss of energy

Non-Pharmacological Treatment

Effective psychotherapies include:

  • Cognitive Behavioural Therapy
  • Interpersonal psychotherapy
  • Stress management / coping skills
  • Marital and family issues

Pharmacological Treatment Adults:

A: Amitriptyline (PO) 50–75 mg daily at night, increase gradually to a maximum of 150 mg daily. Elderly: Initially 25–50 mg. Max. 75mg


S: Fluoxetine (PO) 20mg daily (preferably in the morning), may increase up to 60mg/day)


S: Fluvoxamine (PO) initially 50–100mg daily


D: Citalopram (PO) 20mg daily in the morning or evening increase if necessary to a maximum of 60mg daily (Elderly maximum 40mg daily)


Refer to the next level in the following situations:

  • Suicidal ideation
  • Major depression with psychotic features
  • Failure to respond to available antidepressants
  • Patients with concomitant medical illness, e.g. heart disease, epilepsy
  • Poor social support systems
  • Pregnancy and lactation
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