5847 eCPE Depression

Depression 2022
MAY
Essential CPE
PSA Committed to better health

Essential CPE
Depression The views expressed by the authors of this Essential CPE module are their own and not
necessarily those of the publisher, which is PSA, nor the editorial staff and review panel, and
May 2022
must not be quoted as such. Every care is taken regarding the accuracy of the module, but the
publisher accepts no responsibility for errors, omissions or inaccuracies contained therein.
Contributor
© Pharmaceutical Society of Australia Ltd, 2022
Dr Manya Angley BPharm PhD Adv Pract Pharm AACPA FPS FSHP
Disclaimer
Dr Manya Angley is an accredited pharmacist and an advanced practice pharmacist. She held
academic appointments (teaching and research) in the School of Pharmacy and Medical The Pharmaceutical Society of Australia Ltd has made every effort to ensure that, at the date
Sciences at the University of South Australia from 1990 to 2010. In 2010 she established Manya of publication, the document is free from errors and that advice and information drawn upon
Angley Research and Consulting (MARAC) and has been a general practice pharmacist since have been provided in good faith. Neither the Pharmaceutical Society of Australia Ltd nor any
2012. MARAC holds contracts to deliver quality use of medicines services and residential person or organisation associated with the preparation of this document accepts liability for
medication management reviews at various aged care homes in Adelaide. Her special interests any loss which a user of this document may suffer as a result of reliance on the document and
include mental health, disability and pain. in particular for:
Reviewer • use of the document for a purpose for which it was not intended
Hun Liang Oon BBiomedSc, MPharm, PGCertPsychTher, MSHP • any errors or omissions in the document
Hun Liang Oon is the clinical lead pharmacist for mental health at Fremantle Hospital and a • any inaccuracy in the information or data on which the document is based or which are
sessional academic staff member at Curtin Medical School. He graduated with a Master of contained in the document
Pharmacy from University of Western Australia in 2007 and holds a Postgraduate Diploma in • any interpretations or opinions stated in, or which may be inferred from, the document.
Psychiatric Pharmacy from Aston University. Hun has around 10 years of experience working in
various mental health settings and has a special interest in affective disorders. © Pharmaceutical Society of Australia Ltd, 2022
PSA project team This publication contains material that has been provided by the Pharmaceutical Society of
Australia (PSA), and may contain material provided by the Commonwealth and third parties.
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2 Essential CPE – Depression I © Pharmaceutical Society of Australia Ltd.

Contents
Accreditation details 4 Section 4. Management 22
Competency standards 4 Learning objectives: 22
Purpose and scope 5 Goals of treatment 23
Section 1. Overview of depression 6 Psychoeducation 23
Learning objectives: 6 Non-pharmacological management 23
Definition of depression 6 Physical treatments 25
Aetiology and pathogenesis of depression 7 Pharmacological management 25
Epidemiology and statistics 8 Key points: 29
Self-harm and self-injury 9 Multiple choice questions 29
Suicide 9 Section 5. Follow-up and monitoring 30
COVID-19 10 Learning objectives: 30
Treatment of depression 11 Follow-up and monitoring 30
The impact of depression 11 Relapse 31
Key points: 11 Inadequate response 31
Multiple choice questions 12 Treatment-resistant depression 31
Section 2. Assessment and diagnosis 13 Stopping antidepressant treatment 32
Learning objectives: 13 Key points: 33
Risk factors 13 Multiple choice questions 33
Signs and symptoms 14 Section 6. Putting knowledge into practice 34
Screening 14 Learning objectives: 34
Assessment scales 14 Introduction 34
Diagnosis 14 Screening and case-finding 34
Different types of depression 15 Mental health first aid 35
DSM-5 versus ICD-11 15 Management of depression 35
Key points: 15 Monitoring of patients with depression 36
Multiple choice questions 17 Recommended resources for patients and pharmacists 37
Section 3. Principles of treatment 18 Initiatives pharmacists can be involved in to help raise
Learning objectives: 18 awareness of depression 37
Approach to treating adults with major depression 18 Key points: 38
Approach to treating children and adolescents with Multiple choice questions 38

depression 19 Section 7. Case scenario 39
Approach to treating patients with depression who are References 42
pregnant or post-natal 19
Approach to treating depression in older people 20
Key points: 21
Multiple choice questions 21
Essential CPE – Depression I © Pharmaceutical Society of Australia Ltd. 3

Acceditation details
Accreditation code: CESS2201
Accreditation expiry: 07/05/2025
This activity has been accredited for 5 hour(s) of Group 1 CPD (or 5 CPD credits) suitable
for inclusion in an individual pharmacist’s CPD plan, which can be converted to 5 hours of
Group 2 CPD (10 CPD credits) upon successful completion of relevant assessment activities.
How to earn CPD credits

To obtain CPD credits, carefully read through the module, complete the multiple choice questions and submit your answers online to
receive immediate feedback. Visit www.psa.org.au.
Competency standards
Pharmacists can self-assess their abilities against the competency
standards relevant to their role to determine areas in which
further development is needed.
This Essential CPE addresses the following competencies (2016):
Domain 1: Professionalism and ethics Domain 3: Medicines management and patient care
Standard 1.1: Uphold professionalism in practice Standard 3.1: Develop a patient-centred, culturally responsive
approach to medication management
Standard 1.2: Observe and promote ethical standards
Standard 3.2: Implement the medication management strategy or
Standard 1.3: Practise within applicable legal framework plan
Standard 1.4: Maintain and extend professional competence Standard 3.3: Monitor and evaluate medication management
Standard 1.5: Apply expertise in professional practice Standard 3.5: Support quality use of medicines
Standard 1.6: Contribute to continuous improvement in quality
Domain 5: Education and research
and safety
Standard 5.3: Research, synthesise and integrate evidence into
Domain 2: Communication and collaboration practice
Standard 2.1: Collaborate and work in partnership for the delivery
of patient-centred, culturally responsive care
Standard 2.2: Collaborate with professional colleagues
Standard 2.3: Communicate effectively

Purpose and scope
Pharmacists play a key role in recognising mental health multiple treatments, is complicated by psychotic symptoms,
disorders, providing mental health first aid (MHFA) and referring and/or is associated with significant psychiatric comorbidity
patients as appropriate. Although diagnosis of mental health or psychosocial factors”.⁴ The DSM-5 includes two new
disorders is beyond the scope of pharmacists, they play an depressive disorders: disruptive mood dysregulation disorder
important role in ensuring quality use of medicines in people and premenstrual dysphoric disorder. Bipolar disorder is now
with mental health conditions. Quality use of medicines classified separately to depressive disorders in the DSM-5;
encompasses using non-pharmacological strategies wherever therefore, it will not be specifically addressed within this module.
appropriate. The content of this module aligns with the In contrast to DSM-5 and ICD-11, the Royal Australian and
classification and management of depressive disorders within the New Zealand College of Psychiatrists (RANZCP) Clinical Practice
Australian Therapeutic Guidelines: Psychotropic.1 The content also Guidelines for Mood Disorders uniquely combines both depressive
aligns with the current diagnostic classifications of depressive disorders and bipolar disorders.⁵ It considers depressive disorders
disorders in the Diagnostic and Statistical Manual of Mental and bipolar disorders as a spectrum, reflecting the reality of
Disorders (DSM-5)2 and the International Classification of Diseases clinical practice where mania (bipolar disorder) usually emerges
– 11th Revision (ICD-11).3 The focus is on assessing and managing in the context of pre-existing depression that may, or may not,
major depressive disorder (MDD), persistent depressive disorder have been diagnosed as yet. Content within the RANZCP Clinical
(dysthymia), and complex depression. Complex depression Practice Guidelines for Mood Disorders relating to depressive
includes “depression that shows an inadequate response to disorders is also considered within this module.5

Section 1. Overview of depression
Learning objectives Definition of depression

• Discuss the prevalence of depression in Australia. Depression is a broad and heterogeneous diagnosis. Core
• Describe the classification of depressive symptoms. symptoms of depression include depressed mood and/or loss
• Describe the approaches to mood disorder aetiology. of pleasure in previously rewarding or enjoyable activities.2 The
• Describe the impact of depression on the lives of patients severity of the disorder is determined by the number and severity
of symptoms, as well as the degree of functional impairment.
and their carers.
It is important to note that many of the symptoms that occur in
depressive disorders are not too dissimilar to normal changes
that individuals experience; it may be simply the duration
and severity that is deemed unusual or cause for concern. For
example, changes in sleep and appetite, fluctuations of mood,
being able to attend school/work and concentrate, motivation
and lack of drive all vary considerably in normal health, so
determining cut offs can be difficult both subjectively and
objectively. The key issue is whether symptoms are causing any
functional impairment (i.e. imposing any limitations on what
the person can do in their day-to-day activities, both work and
leisure).5

According to the Diagnostic and Statistical Manual of Mental Most people with depression have a mild to moderate form and,
Disorders 5th edition (DSM-5), major depressive disorder is with appropriate care, most recover within a year.⁷ Up to 80%
characterised by a depressed mood (or irritability in children) of people have at least two recurrences during their lifetime;
and/or loss of pleasure or interest in activities for at least two however, for a small proportion of people, depression becomes
weeks.2 To diagnose depression, there is a need to have at least a chronic illness.5,7 Episodes that occur after having achieved
five symptoms with at least one of the core symptoms and at full remission are referred to as recurrent episodes.1 The median
least four of the following symptoms present most days:2 duration of an episode of depression is 16–23 weeks and about
• weight loss or change in appetite 12% of people will not achieve full remission.⁸ Depression is
associated with significant disability that is often not recognised
• insomnia or hypersomnia
and is a major cause of morbidity worldwide.⁹ It is also associated
• psychomotor retardation or agitation
with high levels of mortality and is a leading cause of suicide.8
• fatigue or loss of energy Depression is frequently associated with other psychiatric
• excessive/inappropriate guilt or feelings of worthlessness disorders (particularly anxiety disorders), substance misuse
• indecisiveness or diminished ability to concentrate or think and physical health disorders (such as cardiovascular disease,
• recurrent thoughts of death or suicidal ideation or suicide plan neurological disorders, chronic medical conditions and cancer).10
or attempt.
Another depressive disorder, persistent depressive disorder
(formerly called dysthymia) in the DSM-5, is characterised by a
Aetiology and pathogenesis of
depressed mood most of the time for at least two years, along depression
with at least two of the following symptoms:2 The aetiology and pathogenesis of mood disorders includes a
• feeling hopeless multitude of biopsychosocial factors operating in an interacting
• insomnia or hypersomnia and dynamic fashion. However, the specific aetiological cascades
• overeating or poor appetite ending in diagnosed depression remain elusive. Neither
• fatigue or low energy neuroscience nor genetics has produced a laboratory test to
guide diagnosis of mood disorders.5
• low self-esteem
• indecisiveness or poor concentration. One neurobiological theory is the monoamine hypothesis
of depression. It suggests that levels of monoamine
In children and adolescents, the mood can be irritable, and the
neurotransmitters in the brain (including norepinephrine,
duration of persistent depressive disorder is at least one year.⁶
dopamine and serotonin) are lowered in depression.11 These
To qualify for a diagnosis of persistent depressive disorder, there
neurotransmitters influence the symptoms commonly seen
cannot be a gap of more than two months in these symptoms,
in depression, including amotivation and poor concentration
with no hypomanic or manic episode(s) during this time period,
(dopamine), fatigue and hypersomnia (dopamine and
or diagnosis criteria met for cyclothymic disorder. Furthermore,
norepinephrine) and somatic symptoms (norepinephrine and
the symptoms are not better explained by another disorder,
serotonin).11 The mechanism for these reduced levels is still
cause significant impairment in functioning or distress, and
uncertain.
are not due to a different medical condition or a substance use
disorder.2,6 Other theories include the dysregulation of the hypothalamic–
pituitary–adrenal axis (described in The Hypothalamic–
The severity of depression is determined by the number and
pituitary–adrenal axis in major depressive disorder: a brief primer
severity of symptoms, as well as the degree of functional
for primary care physicians at www.ncbi.nlm.nih.gov/pmc/
impairment. Depending on the severity, major depression can be
articles/PMC181180/) and the psychoanalytical theory of
further classified as mild, moderate or severe.1 The Therapeutic
depression (described in Psychoanalytic and psychodynamic
Guidelines defines these classifications as follows1:
therapies for depression: the evidence base at www.cambridge.
• Mild major depression – symptoms cause distress, and the org/core/journals/advances-in-psychiatric-treatment/article/
person has some difficulty carrying out usual activities. psychoanalytic-and-psychodynamic-therapies-for-depression-
• Moderate major depression – several symptoms may be the-evidence-base/03EC8C9F5C9BAE16B47FC73942FBDA18).
present to a marked degree and the person has considerable
Four distinct and complementary approaches to mood disorder
difficulty carrying out usual activities.
aetiology have been described: the role of stress and coping;
• Severe major depression – symptoms cause considerable
genetics and gene-environment interactions; emerging evidence
distress, agitation or psychomotor retardation and the person for the role of circadian function; and the importance of
is unable to continue usual activities beyond a minimal extent. cognition in both the cause of and ongoing dysfunction that can
Somatic symptoms (e.g. lack of energy, change in appetite, occur in depression.5
pain) are prominent and suicide is a particular risk.
Psychotic depression is a rare form of severe major depression Role of stress and coping
in which patients experience psychotic symptoms such as
delusions, hallucinations or paranoia.1 With respect to stress as a risk factor for depression, research has
focused primarily on stress related to childhood maltreatment
(trauma/abuse/neglect) and the stress of life events in
adulthood.5

The impact of stress on multiple bodily systems is well clear boundaries between these three clusters. In the elderly,
documented. Stress can cause neurochemical changes12 including the role of cognition is even more complicated as vascular
activation of cytokines, stimulation of growth factors (e.g. brain- changes and Alzheimer’s disease are more common than in the
derived neurotrophic factor) and the release of hypothalamic– general population. The onset of depression will compromise
pituitary–adrenal (HPA) axis-related hormones, which can in turn their cognitive functioning and compound their pre-existing
impact depression.13 Exposure to stressors in early childhood may dysfunction. Further, some of the commonly used treatments,
also impair the development of HPA axis and neurobiological such as tricyclic antidepressants (TCAs), have the potential to
response to stress in adulthood. Experiences of chronic and worsen cognitive impairment via their anticholinergic effects.
uncontrollable stress exacerbate negative attributional style14
and trigger a self-reinforcing cascade of neuroendocrine and
inflammatory processes that result in further sensitisation to
Epidemiology and statistics
depressive states among susceptible individuals.13,15 Depression is a common mental disorder affecting more than
Coping explains some of the variance observed in depression 280 million people worldwide.22 It is a leading cause of disability
risk.5 Successful coping with adversity can also decrease the risk and a major contributor to the overall global burden of disease.22
of depression, and resilience is a protective factor. Therefore, Mental health disorders are the largest contributors to the
the development of resilience is a key target of all strategies or non-fatal burden of disease in Australia and are a leading cause
depression management. of morbidity.23,24 The Australian Bureau of Statistics, National
Health Survey 2017–2018 revealed one in ten people (10.4%) had
Genetics and gene-environment depression or feelings of depression, equating to over 2.5 million
Australian adults.25 This is an increase from 8.9% in 2014–2015.25
Depression can run in families and some people have a Key prevalence statistics for depression are listed in Box 1.5
genetically determined increased risk. Family studies and
monozygotic twin concordance studies have also demonstrated Box 1. Key prevalence statistics for depression
a heritable risk for depression.5 The genetics of depressive • 12-month prevalence of major depression 6%
disorders is complex; many thousands of genetic variants are • Lifetime risk of depression 11–15%
likely to be implicated in reciprocal interaction with each other,
• In primary care, one in ten patients present with
environmental exposures and random factors.16 Depression
is unlikely to occur without stressful life events, but the risk of depressive symptoms
developing depression as a result of such an event is strongly • 40% of patients with major depression experience their
genetically determined. Therefore, whether a person develops first episode of depression before the age of 20
a depressive disorder is a complex interplay between genetic • Average age of onset of depression is mid-20s
predisposition, life circumstances and other personal factors. • Gender ratio female:male 2:1
Role of circadian function

Reference: Malhi5
It is evident that circadian and sleep disturbances play a key
role in bipolar disorder, but emerging evidence indicates Prevalence of depression in different
circadian function may also play a role in the pathophysiology of subsets
depression.17 The core symptoms of depression involve circadian
disruption such as: changes in the sleep/wake cycle, diurnal Depression is more common in women than men. Depression
variation in the severity of mood symptoms, and variations in the can affect women at any time in their life; however, major life
daily cyclic levels of hormones and neurotransmitters.18 There transitions such as pregnancy, motherhood and menopause can
is also evidence that the disruption of circadian rhythms is a create physical and emotional stresses for women. In addition,
potential trigger for depressive episodes in vulnerable individuals there are a number of other factors that can contribute to
who are genetically predisposed. Thus, a disturbance in circadian depression in women, including: infertility and perinatal loss,
function may predispose to disorder or relapse; this vulnerability poverty, discrimination, violence, unemployment, isolation and
can be activated by stressors, but also moderated by coping unequal economic and social conditions.
behaviours as taught in behavioural therapies. About one in five young people will experience an episode
of depression before the age of 25.26 The peak period for the
Importance of cognition onset of depression is adolescence and young adulthood, and
most adults who suffer from recurrent depression will have first
A proportion of people with major depressive disorder
experienced it during this period.27
experience significant observable as well as perceived
cognitive impairment19 that correlates with decreased level Between 10 and 15% of older people experience depression.28
of functioning.20 Impaired cognition and functioning also Rates of depression among people living in residential aged care
appears to be linked to the risk of relapse21 and possibly are believed to be much higher, at around 35%.28 People with
significantly worsens the course of the illness; however, data dementia of any type have a high incidence of major depression;
is lacking. Not all people with depressive disorders experience the incidence of depression may be 30% in vascular dementia and
cognitive impairment: some appear to have global impairment, in Alzheimer’s disease, and over 40% in the dementia associated
some specific impairment and others no impairment. The with Parkinson’s and Huntington’s diseases.29 The occurrence of
level of impairment probably exists on a spectrum, without a first major depressive episode in an older adult is a risk factor

for developing dementia. When dementia and depression occur
at the same time, it may be difficult to distinguish between them
Self-harm and self-injury
because the signs and symptoms are similar. However, dementia Self-harm refers to someone deliberately causing pain or damage
and depression are very different conditions that require different to their own body. It can be suicidal or non-suicidal in intent. Self-
responses and treatment, so a thorough assessment by a health injury is a sub-category of self-harm and refers specifically to pain
professional is recommended. In older people, both personal or damage caused without suicidal intent.
carers (e.g. a partner, family member or friend) and professional Some people who self-harm may also have suicidal thoughts.
carers are a valuable source of information. Both personal and Self-harm is usually done in secret and on places of the body
professional carers should be included in healthcare discussions that may not be seen by others.42 The most common type of
and assessment where possible.29 self-harm is cutting, but there are many other types of self-harm,
Indigenous Australians are known to have higher rates of including burning or punching the body, picking skin or sores,
depression. A recent study found a 22% point prevalence of pulling out hair and taking harmful substances (such as poisons
major depressive episodes in an Indigenous cohort.30 This is or medications).42
in accord with studies that have found that the prevalence of
psychological distress31 and depression32 is up to three times Why do people self-harm?
as high for Indigenous Australians as for non‐Indigenous
Self-harm is normally a sign that a person is feeling intense
Australians. The checklist approach as used by the DSM-5 and
emotional pain and distress. In general, people self-harm as a
ICD-11 has limitations with respect to the experiences of First
way of coping. People often talk about harming themselves
Nations people, which includes the psychological effects of
to relieve, control or express distressing feelings, thoughts or
ongoing cultural trauma, racism, poverty, disempowerment, and
memories. Some people harm themselves because they feel
social exclusion. A greater phenomenological understanding of
alone, while others do so to punish themselves due to feelings
depression in a cross-cultural context has been highlighted as a
of guilt or shame. However, the relief they experience after
necessary aspirational goal.
self-harming is only short term and at some point the difficult
Rates of mental health disorders, including depression, are feelings usually return. With the return of these feelings often
higher among people with intellectual disability (ID) and comes an urge to self-harm again. This cycle of self-harm is often
developmental disability than for the general population.33-35 Best difficult to break.
estimates are that the prevalence of mental health disorders in ID
Although most people who self-harm are not trying to kill
is two to three times the rate of the general population.34 More
themselves, it is possible that they hurt themselves more than
than half of all people with ID have a psychiatric or mental illness.
they intended to, which can result in accidental suicide. People
Very high rates of mental health disorders, especially depression
who repeatedly self-harm may also become suicidal and feel
and anxiety, have also been reported in people on the autism
hopeless and trapped.
spectrum.36
The mental health of lesbian, gay, bisexual, transgender, queer
(or questioning), intersex, and asexual (LGBTQIA+) people is Suicide
among the poorest in Australia.37 There is research evidence Depression is one of a group of psychiatric conditions commonly
connecting the experience of discrimination with an increased associated with suicide. In 2019, Australians lost 145,703
risk of developing depression.38 Depression rates are reported years of healthy life due to suicide and self-inflicted injuries.43
as 30% occurring overall amongst LGBTQIA+ people and range Threequarters of the total burden of suicide and self-inflicted
from a high of 50% of trans-males to a low of 24.5% of males.39 injuries in 2019 occurred in males (109,144 disability-adjusted
Exposure to racial discrimination is widely understood as life years, DALY) at a rate of 8.7 per 1,000 population, accounting
a social determinant of health and a contributing factor to for an estimated 4% of total burden among males.43 In contrast,
health inequities between racial and ethnic groups. The World suicide and self-inflicted injuries were responsible for 36,558 DALY
Health Organization (WHO) has identified that mental health in females in 2019, at a rate of 2.9 per 1,000, accounting for an
disorders, including depression, in populations from conflict estimated 1.5% of total burden among females.43 Among those
settings are high.40 However, systematic research into the aged 15 and over, males suffered a higher burden (and rate) of
prevalence of mental health disorders and mental health service suicide and self-inflicted injuries than females in each age group.43
utilisation of refugees and immigrants in Australia is scant.41 There are a number of reasons for this, including males being
What is known is that factors contributing to increased risk of less likely to recognise, talk about and seek help for depression.44
mental health problems in culturally and linguistically diverse Overall, the proportion of total burden due to suicide and self-
(CALD) populations include low proficiency in English, separate inflicted injuries was highest among people aged 25–34 (25%),
cultural identity, loss of close family bond, stresses of migration followed by those aged 15–24 and 35–44 (both 21%).43
and adjustment to the new country, limited knowledge of the While suicidal thoughts and behaviours can occur at any time, there
health system, trauma exposure before migration, and limited is believed to be an increased risk when antidepressants are started
opportunity to appropriately use occupational skills. Factors that (although this has only been found to be statistically significant in
appear to be protective of mental health include religion, strong certain populations).1,45,46 For this reason it is important to weigh
social support and better English proficiency.41 up the harms and benefits of using a medicine associated with
emergent suicidality in a person who has depression especially for a
patient considered to be at risk of suicide.

If after weighing up the harms and benefits, a patient is The World Psychiatric Association (WPA) has provided a summary
prescribed a medicine that is known to increase suicidal ideation of risk factors for suicide that are associated with the COVID-19
or suicide risk, it is important they are informed of the risk and pandemic. This can be extrapolated as risk factors for depression
have an action plan to follow should suicidal thoughts occur. (Table 1).51 COVID-19-associated risk factors are affected both
As a precaution, the prescriber should have regular reviews positively and negatively by either the disease itself or associated
with the patient (and their family, carers or significant others if social/public health and economic measures. Protective factors,
applicable) in the first few months of treatment and if there is a identified by the WPA, are essentially initiatives and strategies
change of dose or the medicine is stopped.1 Pharmacists should that address these risk factors.
be hypervigilant. If a patient discloses suicidal thoughts, mental
Table 1. COVID-19-associated risk factors for depression
health first aid should be employed and the patient referred to
the emergency department. Risk Description
Societal risk Increased pressure on healthcare systems
COVID-19 factors Increased allocation of resources to the acute
response to the pandemic
The threat of the COVID-19 illness and the measures
Decreased focus on mental healthcare
governments have put in place to curb its spread has brought a
Increased buying and stockpiling of medication,
range of new social, physical and psychological risks that health
and increased barriers to access due to
professionals need to consider. Health professionals and mental containment measures
health patients need rapid access to high-quality, evidence- Media sensationalising of the situation
based information to help guide their shared decision-making. impacting on the perception of risks
As with telehealth in other areas of healthcare, acceptance and Barriers to help-seeking behaviour through
uptake of telepsychiatry has accelerated during the pandemic.47 containment measures
The first year of COVID-19 in Australia: direct and indirect health Community Decreased access to healthcare and social care
effects report notes that impacts of the pandemic in Australia risk factors De-prioritisation of mental health
appeared to temporarily increase levels of psychological distress,
with the average level of psychological distress returning to
pre-pandemic levels by April 2021.48 The increased psychological
distress seen was particularly an issue for adults aged 18–45
Relationship Increased isolation and lack of social support
risk factors Increased relationship conflict as additional
and even once average levels returned to pre-pandemic levels,
strains are put on relationships
psychological distress continued to be higher for young people.48
Decrease in opportunities for contact with
The proportion of people experiencing severe psychological people outside of the home who can provide
distress also continued to be higher in April 2021 (9.7%) than in support
February 2017 (8.4%). However, despite this, suicide rates appear Loss of significant others due to death by
to have remained at pre-pandemic levels.48 It has previously been COVID-19
shown that while suicide rates may momentarily decrease during Increased interpersonal violence and abuse
times of crises, once the immediate crisis has passed, suicide within families or households
rates increase. The full impact of the pandemic on the mental Decreased access to formal and informal help
health of Australians and suicide rates remains to be realised. Reduced opportunities of communal
experiences and activities
Australian research examining the effects of the COVID-19
pandemic on depression identified a number of factors Individual Worsened symptoms of mental disorders
significantly associated with higher baseline depression scores, risk factors Reduction in wellbeing through social isolation
and quarantine
including younger age, being female, greater COVID-19-related
Reduced treatment compliance
work and social impairment, COVID-19-related financial distress,
Increased use of alcohol
having a neurological or mental illness diagnosis, and recent
Increased job or financial loss due to the
adversity.49 The authors concluded that “early intervention economic crisis
to ensure that vulnerable people are clinically and socially Increased hopelessness through potential loss
supported during a pandemic should be a priority.”49 of friends and family, loss of job, and general
Canadian research has identified that certain subgroups uncertainty
(including Indigenous people, racialised groups, individuals who Worsened chronic pain through reduced care
and increased stress
identify as LGBTQIA+, people with a disability, and/or people
Decreased access to community activities
with mental health problems) are two to four times as likely to
Negative impact on diet through irregular
have had suicidal thoughts or tried to harm themselves since the
eating patterns, diminished access to fresh food
outbreak of COVID-19.50 This suggests these subgroups may be and frequent snacking, stress and anxiety
more vulnerable to the negative mental health impacts of the Decreased physical activity due to containment
pandemic. To support these individuals, the unique underlying measures
factors contributing to the negative mental health impact of Increased anxiety and stress due to (in)direct
COVID-19 for each specific subgroup needs to be identified consequences of the pandemic
and targeted strategies to manage these developed and Reference: World Psychiatric Association51
implemented.50

Treatment of depression When depression develops in the adolescent years, it can be
particularly challenging.52 The longer the period between onset
Treatments for depression include psychological and biological of depressive symptoms and treatment in a young person, the
interventions. Although there are known, effective treatments longer they will take to respond to treatment.53 In addition,
for depression, many people receive no treatment. The World delays in treatment increase the likelihood of chronic or recurrent
Health Organization (WHO) has highlighted that the discrepancy symptoms and episodes.54 There are a number of important
that exists between the number of people needing treatment developmental tasks that occur during adolescence and early
for mental disorders (including depression) and the number adulthood, including establishing a sense of self that is distinct
receiving treatment represents a major public health challenge. from their parents, developing new interests and skills, forming
The discrepancy is greatest in those with low socioeconomic and maintaining relationships (including sexual relationships),
status and those living in low-income countries. This completing further study and finding a job.26 Illness during
phenomenon is known as the ‘mental health treatment gap’. this time can interrupt these key developmental tasks, causing
sufferers to fall behind their peers.26 This can lead to social
Psychological treatments isolation, demoralisation and reduced potential for achievements
in the future.26
Psychological treatments can help people with depression
change their thinking patterns and improve their coping skills so In comparison to other types of mental health disorders,
they are better equipped to deal with life’s stresses and conflicts. depressive disorders have a particularly negative impact
They have a role to play in helping people both recover from on young people’s ability to live their day-to-day life.55 In an
depression and stay well by identifying and changing negative Australian study, over 40% of children and adolescents with
thoughts and behaviour. depression reported that their symptoms had a severe impact on
their daily functioning, and an additional 35% reported moderate
There are a range of effective psychological treatments for
impact.55 In turn, this can have long lasting effects on a young
depression and different delivery options, including one-on-
person’s life, including reduced workforce participation, lower
one with a professional and in a group environment. A growing
income and lower living standards in adulthood.56 Young people
number of online programs, or e-therapies, that can overcome
who experience multiple episodes of depression have a high risk
access barriers and expand options for patient choice are also
of experiencing these disadvantages in adulthood.56 Because
available.
40% of patients with major depressive disorder experience their
first episode of depression before the age of 20 (see Box 1), and
Medical treatments depression is often recurrent, it places a large burden on the
Antidepressant medicines are the mainstay of medical treatment community.57 For these reasons, early treatment of depression
for depression. Treatment with medicines can be very useful in in adolescence is crucial and should focus on both reducing
the treatment of moderate to severe depression. Antidepressants symptoms and restoring developmental trajectory (e.g. getting
are generally prescribed when other treatments have not been them back to work/study). This has the potential to reduce
successful or when psychological treatments are not possible disruption to relationships within the family, difficulties with
due to the severity of the condition or a lack of access to the employment and education, the need for inpatient care, the risk
treatment. of suicide, and the likelihood of social isolation.58
The impact of depression Key points

During a depressive episode, the person experiences significant • Mental health disorders are the largest contributors to the
difficulty in personal, family, social, educational, occupational non-fatal burden of disease in Australia and are a leading
and/or other important areas of functioning.22 The effects of cause of morbidity.
depression can be long lasting or recurrent and can markedly • 10% of Australians report having depression or depressive
affect a person’s ability to live a fulfilling life. Depression is a symptoms.
chronic, often lifelong, illness and while acute episodes can • The four prominent and complementary approaches
be successfully treated with a reasonable level of functioning
to mood disorder aetiology are: the role of stress and
restored, the underlying vulnerability is unlikely to be rectified.
coping; genetics and gene-environment interactions;
There is no cure for depression.5
emerging evidence for the role of circadian function; and
the importance of cognition in both the aetiology and
ongoing functional compromise associated with mood
disorders.
• Impacts of the COVID-19 pandemic have increased levels
of psychological distress, particularly for young people.
• Depression in young people can have long-lasting effects
on a young person’s life, including reduced workforce
participation, lower income and lower living standards in
adulthood.

Multiple choice questions
1. Which ONE of the following statements about 4. Which ONE of the following factors is likely to be
depression is TRUE? protective against psychological stress, and in turn
mental ill health, associated with the COVID-19
a) Successful coping with adversity can increase the pandemic?
risk of depression and resilience is a contributing
factor. a) Targeted and tailored efforts to support vulnerable
individuals.
b) Four out of five people who have an initial diagnosis
of depression have at least two recurrences during b) Increased use of alcohol.
their lifetime. c) Decreased access to community activities.
c) The aetiology of depressive disorders is determined d) Decreased physical activity due to containment
by a single genetic variant. measures.
d) Untreated depression leads to cognitive impairment.
5. Depression can have long lasting effects on a young
2. Depression is more common in women than men. person’s life. Which ONE of the following is the LEAST
Which ONE of the following is LEAST likely to likely consequence of chronic depression?
contribute to the higher prevalence of depression in
a) Reduced workforce participation.
women?
b) Lower income.
a) Pregnancy, motherhood, and menopause.
c) Lower living standards in adulthood.
b) A high level of health literacy and strong social
support. d) Greater societal participation.
c) Unequal economic and social conditions. 6. Major depression can be classified as mild, moderate or
d) Negative experiences such as poverty, discrimination severe. Which ONE of the following is CORRECT?
and violence. a) In mild major depression somatic symptoms are
prominent.
3. Which ONE of the following statements about self-
injury is FALSE? b) In moderate major depression symptoms cause
significant distress and agitation.
a) In Australia, the majority of suicide and self-inflicted
injuries occur in women. c) In severe major depression somatic symptoms are
prominent.
b) Suicidal thoughts and behaviours can emerge when
starting antidepressants. d) In moderate major depression there is limited
impairment in the ability to carry out usual activities.
c) In Australia, the age group most likely to suicide or
self-inflict injuries are those aged between 25 and 34
years.
d) If a person is experiencing suicidal ideation,
developing an action plan can save lives.

Section 2. Assessment and diagnosis
Learning objectives Risk factors

• Identify risk factors for the development of a depressive Cause of depression
disorder. The exact cause of depression is not known; however, it is usually
• Outline the key symptoms of depressive disorders. multifactorial, involving a combination of recent events, longer-
• Describe the methods used to identify and diagnose term or personal factors and a genetic predisposition.38
depressive disorders.
• Discuss the criteria for diagnosis of major depressive Life events
disorder. Life events that can lead to depression include both ongoing
difficulties and recent events. Ongoing difficulties are more likely
to cause depression than recent events; however, recent events
can trigger depression in someone at risk due to previous bad
experiences or personal factors.38 Life events that have been
associated with the development of depression include11,38:
• Ongoing difficulties – long-term unemployment, living in
an abusive or uncaring relationship, long-term isolation
or loneliness, prolonged work stress, poor social support,
childhood trauma, lower income.
• Recent events – job loss, recent childbirth.

Personal factors Screening
A number of personal factors have been associated with the Pharmacists are well positioned to screen for depression and
development of depression, including11,38: have been found to be able to identify undiagnosed adults
• Family history of depression – however, having a parent using depression screening tools. However, routine screening is
or close relative with depression does not mean you will not generally recommended as there is limited evidence on the
automatically get it as life circumstances and other personal effect of it on clinical outcomes.60 If a pharmacist becomes aware
factors also play a role. that a patient is experiencing any of the symptoms presented
• Certain personality traits – particularly a tendency to worry in Table 2, it is cause for concern and may be appropriate to ask
a lot, low self-esteem, perfectionism, sensitivity to personal specific screening questions.
criticism, self-critical or negative. The National Institute for Health and Care Excellence (NICE)
• Serious medical illness (such as diabetes, cancer, stroke, heart Depression in adults: recognition and management clinical
attack, dementia and obesity) – the stress of coping with the guidelines 20094 recommends asking people (aged 18 and over)
condition can lead to depression. who have signs of depression two questions:
• Drug and alcohol use – can both lead to and result from
• During the last month, have you often been bothered by
depression.
feeling down, depressed or hopeless?
• During the last month, have you often been bothered by
Signs and symptoms having little interest or pleasure in doing things?
Table 2 provides a summary of the key symptoms observed in If the answer to either question is yes, further detailed
depressive disorders. questioning and assessment by a GP is required. Pharmacists
should talk with anyone they are concerned about and advise
Table 2. Key symptoms of depression them to speak with their GP where appropriate. Any patient
identified to be experiencing suicidal ideation should be
Category Symptoms
immediately referred to an emergency department.
Emotional Low or depressed mood
symptoms Irritable and sensitive to criticism
Persistent sadness Assessment scales
Loss of enjoyment or pleasure (can result in Assessment scales can sometimes be a useful tool for screening,
withdrawal from regular activities, including
assessing and monitoring the success of treatment in patients
looking after personal appearance)
Feeling angry and being aggressive with depressive symptoms. However, they should not be relied
on solely; instead, they should be used in conjunction with
Physical Fatigue, lack of energy and tiredness
clinical relationship-based care.1
symptoms Significant change in appetite and weight
(poor appetite is common but overeating can There are a large number of scales available. Some are designed
occur) for clinician use (e.g. Hamilton Depression Rating Scale, Geriatric
Difficulty sleeping (waking in the middle of Depression Scale and Cornell Scale for Depression in Dementia)
the night or very early and having difficulty while others are designed for patient use and are available online
getting back to sleep) or sleep may be (e.g. Patient Health Questionnaire-9, Depression Anxiety and
prolonged Stress Scale-21, and the Geriatric Depression Scale).
Increased sensitivity to pain (can feel muscle
tension, aches and pains and headaches)
Slowed and heavy movements including Diagnosis
altered/reduced facial expressions Depressive disorders can only be diagnosed by qualified
Loss of sex drive clinicians who are trained to assess and diagnose mental
Agitation illness (e.g. GPs, psychiatrists).26 Depression is most commonly
Cognitive Difficulty concentrating and making decisions diagnosed by GPs who are guided by classification systems such
symptoms Worry and pessimism as DSM-5.2
Feeling worthless or hopeless
Thoughts about death (can feel hopeless and
trapped)
Slow thinking and memory problems
Guilt
Social Social withdrawal
symptoms Deliberate isolation
Reference: Lyness
59

Different types of depression
Key points
Formal systems for the diagnosis of mental illness (DSM-5; ICD-
11) define a number of different types of depressive disorder, • The causes of depression include complex interactions
including: between social, psychological and biological factors.
• Life events such as childhood adversity, loss and
• major depressive disorder
unemployment contribute to and may catalyse the
• persistent depressive disorder (includes what was diagnosed
development of depression.
as chronic major depression and dysthymia in DSM-4)
• Depressive disorders can only be diagnosed by qualified
• disruptive mood dysregulation disorder (initial diagnosis must
mental health clinicians who are trained to assess and
be made between 6 and 18 years of age)
diagnose mental illness (e.g. GPs, psychiatrists).
• premenstrual dysphoric disorder
• Key symptoms of depression cluster into emotional,
• substance/medication-induced depressive disorder cognitive, physical, and social indicators.
• depressive disorder due to another medical condition • According to the DSM-5, for a diagnosis of major
• other specified mood disorder. depressive disorder, a minimum of five symptoms is
Core symptoms of some of the key DSM-5 depressive disorders required, one of which must be low mood or loss of
are summarised in Table 3. interest, nearly every day over two weeks.
The DSM-5 criteria for depressive disorders provide a useful • According to DSM-5, persistent depressive disorder is
guide for when antidepressant treatment will be beneficial. Once diagnosed when an affected adult reports a history of two
a diagnosis is made, practitioners need to consider the severity or more depressive symptoms over a period of two years
(based on the number of symptoms and the functional impact), or longer.
duration of symptoms and the number of prior episodes in order • Greater numbers of depression symptoms are associated
to decide the most appropriate therapeutic intervention(s). with greater morbidity.
• Rating scales are useful tools for screening, assessing
and monitoring the success of treatment in patients with
DSM-5 versus ICD-11 depressive symptoms.
The DSM-5 and ICD-11 are both classification systems for
mental health disorders. The DSM-5 is published by the
American Psychiatric Association while the ICD-11 is published
by the World Health Organization. There has been an effort
to harmonise the systems in the most recent editions of both
systems. However, there are still differences as a result of different
priorities and different interpretation of the evidence. While these
diagnostic manuals have a number of benefits, including aiding
consistent diagnoses and as a teaching resource, they have
their limitations. These include the inability of limited diagnostic
codes to cover the complexity of patient presentations, the
overlapping of criteria such that a patient’s symptoms may fit
multiple disorders and the use of language that is not adapted
to the needs of populations such as Indigenous peoples. These
limitations should be kept in mind when using these tools.

Table 3. Core symptoms of different types of depressive disorders
Depressive disorder Core symptoms
Major depressive disorder Five or more of the following symptoms, present during the same two-week period, at least one of which
(MDD) is a core symptom.
Core symptoms
• Depressed mood most of the day nearly every day (depressed or irritable mood in adolescents)
• Loss of interest or pleasure in most things
Other symptoms
• Appetite disturbance or significant weight change
• Sleep disturbance
• Fatigue or loss of energy
• Restlessness or feelings of being slowed down
• Worthlessness or guilt
• Difficulty concentrating and/or making decisions
• Recurrent suicidal ideation or suicidal behaviour
Additional notes
• Symptoms are causing functional impairment
• Symptoms are not better explained by substance abuse, medicine side effects or another medical
condition
• Severity criteria (mild/moderate/severe) are provided in DSM-5
Persistent depressive Depressed mood for most of the day, for more days than not, for at least two years. In children and
disorder (dysthymia) adolescents, mood can be irritable, and duration must be at least a year.
AND
Two or more of the following symptoms:
• Appetite changes
• Sleep changes
• Low self-esteem
• Fatigue
• Poor concentration or difficulty making decisions
• Hopelessness
Additional notes
• Symptoms are causing functional impairment
• Symptoms are not better explained by substance abuse, medicine side effects or another medical
condition
• This diagnosis includes both chronic MDD and what used to be called dysthymia (in DSM-4)
Disruptive mood Characterised by chronic, severe irritability or angry mood with frequent and severe verbal or non-verbal
dysregulation disorder temper outbursts (onset before age 10 years). These outbursts are both grossly out of proportion with the
(should only be diagnosed perceived trigger, and not in keeping with age-appropriate behaviour.
when patient is between 6 Additional assessment considerations for disruptive mood dysregulation disorder (from DSM-5):
and 18 years old)
• Careful assessment is needed to distinguish this disorder from other DSM-5 disorders.
• Early intervention is important because the risk of functional decline is significant.
• Risk assessment should be prioritised because suicidal behaviour, severe aggression and deterioration in
functioning are common.
• This disorder is thought to be more common in children (aged 6-12 years) than adolescents.
Premenstrual dysphoric Characterised by mood disturbance (depressed mood, mood swings, irritability or anxiety) that repeat-
disorder edly occurs during the premenstrual phase (the week before menses) and remit within a few days of
onset of menses.
In addition to mood disturbance at least one of the following symptoms must be present:
• Decreased interest in usual activities
• Difficulty concentrating
• Lack of energy
• Change in appetite
• Sleep disturbance
• A sense of overwhelm or being out of control
• Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of bloating, or
weight gain
References: Scanlan26, Mackinnon11, American Psychiatric Association2

7. Which ONE of the following personality traits is NOT 10. Which ONE of the following statements regarding the
likely to increase risk of depression? diagnosis of depressive disorders is CORRECT?
a) Tendency to worry a lot. a) Routine screening of patients for depressive
disorders has been found to be cost efficient.
b) Low self-esteem.
b) Assessment scales can be used by appropriately
c) Insensitive to personal criticism.
qualified health care professionals to diagnose
d) Perfectionism. depressive disorders.
8. Which ONE of the following are symptoms of c) Diagnosis of a depressive disorder can only be made
depression that cluster to the emotional domain? if all of the criteria set out in a diagnostic tool (DSM-5
or ICD-11) are met.
a) Difficulty sleeping, increased sensitivity to pain, loss
d) Diagnostic tools (DSM-5 and ICD-11) can be used
of sex drive.
to help guide appropriately qualified clinicians in
b) Irritable, withdrawal from regular activities, lack of diagnosing depressive disorders.
regard for personal appearance, being aggressive.
c) Worry and pessimism, slow thinking, memory 11. According to the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5), which ONE of the
problems and guilt.
following is CORRECT regarding the diagnosis of major
d) Social withdrawal, deliberate isolation, significant depressive disorder in adults?
change in appetite and weight.
a) The patient must be experiencing a depressed
9. Which ONE of the following statements is TRUE about mood most of the day nearly every day and a loss of
premenstrual dysphoric disorder? interest or pleasure in most things.
b) Non-core symptoms that can be used for diagnosis
a) Factors that differentiate premenstrual dysphoric
include sleep disturbance, fatigue, difficulty
disorder from other affective disorders include
concentrating and excessive fear.
aetiology, duration and temporal relationship with
the menstrual cycle. c) The patient must be experiencing at least six of the
listed symptoms, including at least one of the core
b) Premenstrual dysphoric disorder is characterised by
symptoms.
physical and emotional symptoms experienced days
before a woman’s period resulting in mood swings, d) The patient must be experiencing a depressed mood
craving for food and depression. most of the day nearly every day or a loss of interest
or pleasure in most things.
c) It is estimated that as many as three of every four
menstruating women have experienced some form
of premenstrual dysphoric disorder.
d) Premenstrual dysphoric disorder symptoms include
hot flushes, irritability, mood swings, insomnia, dry
vagina, difficulty concentrating, mental confusion,
stress incontinence, urge incontinence, vasomotor
symptoms and insomnia.

Section 3. Principles of treatment
Approach to treating adults with

Learning objectives
major depression
• Identify key factors which influence the treatment
approach for major depression. There is no cure for depression. However, there are a number of
• Explain treatment guidelines and protocols for the effective treatments to manage acute episodes.5 Management
focuses on eradicating symptoms, restoring functioning to a
management of major depression in different patient
reasonable level, improving quality of life, reducing suicidality
populations.
and preventing relapse.11 In adults with major depression,
• Identify the key differences in the treatment approach for
management includes psychosocial interventions and, when
different patient populations.
required, medication.
At the time of diagnosis, patients should be provided with
psychoeducation to help them understand the nature of their
diagnosis and treatment options available, and as a means
to encourage self-management and decrease stigma.5 In
addition patients should be provided with support to address
contributing lifestyle factors and psychosocial interventions
(e.g. stress management and self-coping skills) should be
implemented to manage contributing psychosocial factors
such as unemployment and interpersonal stress. More details

on psychoeducation and lifestyle modification are provided in
Section 4.
Approach to treating children and
Beyond psychoeducation, lifestyle management and
adolescents with depression
psychosocial interventions, choice of treatment influenced by the There are fewer clinical trials of first-line treatments for major
level of severity and patient preference and a shared decision- depression in children and adolescents than adults, and as
making approach with patients should be employed. a result optimal treatment for this group is less clear.5 The
The general treatment approach based on severity is outlined in general principles for treating major depression in children and
Table 4. adolescents are similar to those for adults but the following
points should be taken into consideration.
Table 4. General treatment approach for major depression
based on level of severity For children and adolescents with major depression1,5:
• psychological therapies are preferred
Severity General treatment approach
• in the first instance, mild major depression should be managed
Mild major • Initial treatment options include
psychotherapy, antidepressants, with active monitoring
depression
supportive interventions (e.g. psychosocial • moderate to severe major depression should usually
interventions, lifestyle support) and be managed, in the first instance, with psychological
computer-based treatment (e.g. cognitive interventions such as cognitive behavioural therapy (CBT) or
behavioural therapy). interpersonal therapy (IPT)
• Initial therapy choice should be guided by • psychosocial management should include identifying and
patient preference.
addressing the specific factors that may be contributing
• Antidepressants are not routinely
recommended as initial treatment choice; to their disorder, such as family conflict, parental mental
however, they can be used if other health issues, physical or sexual abuse (mandatory reporting
interventions are unavailable or based on guidelines must be followed), difficulties at school or problems
patient preference. with their peers
Moderate • Either psychological therapies or • there is limited data on antidepressant use in children and
major antidepressants can be used. adolescents as they are poorly represented in clinical trials
depression • Initial treatment choice should be based on • pharmacotherapy should ideally be prescribed by a clinician
patient preference. with expertise in the use of these medicines in children and
• Some patients may benefit from a adolescents
combination of psychological and
antidepressant therapy. • if pharmacotherapy is prescribed, it should always be used in
• Close follow-up and support are important combination with psychotherapy
during the initiation phase of treatment to • if antidepressants are prescribed, close monitoring is required
assist with adherence and reduce the risk of as young people are more susceptible to suicidal thoughts
self-injury/suicide. and activation symptoms (such as disinhibition, impulsivity,
Severe major • Start treatment with an antidepressant. insomnia, restlessness, hyperactivity, and irritability)
depression • Consider suitability of concurrent • pharmacotherapy should only be used in children as part of a
psychotherapy for the individual patient. comprehensive management plan.
• Electroconvulsive therapy (ECT) can be used
for certain forms of severe depression.
• If patient has agitation as a symptom, an Approach to treating patients with
antipsychotic or short-term benzodiazepine
may help.
depression who are pregnant or
• Close follow-up and support are important post-natal
during the initiation phase of treatment to
assist with adherence and reduce the risk of Major depression is common during pregnancy and the post-
self-injury/suicide. partum period.1,5 Depression in pregnancy can have an adverse
References: Psychotropic Expert Group1, MacKinnon11 effect on the developing fetus.1,5 In the post-natal period,
depression can have an adverse effect on the mother–infant
The risk of suicide can be increased in the early stages of
relationship and if untreated could bring harm to the infant.1,5
pharmacological treatment.1 Patients (and if appropriate, their
In addition, suicide is the leading cause of death in the perinatal
family/carers) should be educated about the possible increased
period.1,5 For these reasons, it is very important that perinatal
risk of suicidal ideation and should also be closely monitored for
depression is identified and treated. The general principles of
suicide risk.
treating major depression during the pregnancy and the post-
Major depression is predominantly managed in primary care natal period are similar to the general population but with some
or community settings. However, treatment in hospital may be additional considerations required, including1,5:
required for certain patients, including those with symptoms of
• It is especially important to optimise psychosocial support
psychosis, at significant risk of harm to themselves or others, with
during this time.
inadequate social supports, who are not adequately caring for
• Psychological therapies should be offered to all women with
themselves (e.g. not eating/drinking) or with treatment-resistant
depression.1 perinatal depression.

• There are some risks associated with the use of antidepressant
medicines in the perinatal period and as such, they should
Approach to treating depression in
be reserved for patients with severe depression or where older people
psychological treatment has been ineffective or is not
Depression in older people can be part of a lifetime disorder
appropriate.
or may be a new presentation. The management of depression
• During pregnancy, there is a need to balance reducing the in older people follows a similar approach to the general
psychotropic effects on the fetus with the impact of poorly population with some important extra considerations. Given
controlled depression on the fetus. the increased risks of pharmacological treatment in older
• In patients with pre-existing depression who become people, some guidelines recommend considering non-
pregnant, the importance of effectively treating their pharmacological strategies initially. However, the choice of
depression should be emphasised (patients often stop initial treatment will depend on a number of factors including
pharmacological therapy because of perceived risk to the the severity, type and chronicity of the depressive episode as
fetus). well as the patient’s comorbidities, access to treatment and
• Patients with pre-existing depression who become pregnant patient preference. Processes associated with ageing and
should have their treatment reviewed to determine it is still changes in life circumstances put older adults at unique risk of
the most appropriate treatment for them (in high-risk cases, encountering factors that can contribute to depression, such
the same treatment is usually continued). as loneliness, lack of social and support networks, caregiving
• If antidepressant therapy is started in pregnancy, a selective demands, experiences related to grief and loss, physical illness
serotonin reuptake inhibitor (SSRI) other than paroxetine can and increased dependence on others to carry out day-to-day
be used (paroxetine is associated with a small increased risk of activities (and the resultant loss of independence and dignity).63,64
fetal heart defect). Sertraline is most commonly used because Psychosocial interventions should be considered to help manage
it has the most safety data. these factors. With respect to psychological therapies, a number
• Starting fluoxetine in someone who is breastfeeding or of these have been found to be effective in older patients,
someone who is pregnant and intends to breastfeed should including cognitive behavioural therapy (CBT) and interpersonal
be avoided as it has the highest reported concentrations of all therapy (IPT).5 When determining if pharmacological treatment
SSRIs in breastmilk. If a pregnant or breastfeeding patient is is appropriate, there are a number of considerations that are
already on fluoxetine it should be continued. especially important in older patients, including1,5,63:
• Choice of treatment in both pregnancy and the post-natal • Falls risk – falls are a common health concern for older
period depends on the severity and other individual patient people and older people experience greater injury from falls.
factors such as previous treatment response. Medicines used to treat depression (including antidepressants)
• Treating severe depression in pregnancy and the post- can contribute to falls risk and the benefits and harms of
natal period can be complex and require a specialised pharmacological therapy need to be weighed up before
interdisciplinary approach. prescribing.
More detailed information of the management of depression • Renal and hepatic function – older people are more likely
in the perinatal period can be found in the Mental Health Care to have impaired renal and hepatic function and dose
in the Perinatal Period Australian Clinical Practice Guidelines adjustments may need to be made for certain medicines.
released in 2017. These are available at cope.org.au/wp-content/ • Bleeding risk – selective serotonin reuptake inhibitors (SSRIs)
uploads/2017/10/Final-COPE-Perinatal-Mental-Health-Guideline. and serotonin and norepinephrine reuptake inhibitors (SNRIs)
pdf. Pharmacists should consult a medicines in pregnancy and increase the risk of bleeding when combined with other drugs
breastfeeding reference for more detailed information on the use that affect the clotting process.
of specific medicines in pregnancy and breastfeeding. • Syndrome of inappropriate antidiuretic hormone secretion
(SIADH) – SSRIs are associated with SIADH (risk is greatest in
early treatment) and older people may be more susceptible to
this adverse effect.
• QT interval prolongation – antidepressants may increase
the risk of QT interval prolongation and associated
tachyarrhythmia and this risk is likely to be greater in older
people, in patients with cardiovascular disease and those on
other medicines.
• Sensitivity to adverse effects – older people often need a
more gradual dose titration and lower doses as they are more
sensitive to adverse effects (e.g. hyponatraemia with SSRIs).
• Polypharmacy – polypharmacy is common in older people;
drug and comorbidity interactions need to be carefully
considered.

Key points
• Psychoeducation at the time of diagnosis with a depressive disorder is important to help patients understand their diagnosis
and encourage self-management.
• Psychosocial interventions should be implemented for all patients to manage contributing psychosocial factors such as
unemployment and interpersonal stress.
• Psychological therapy can have a role to play for all severities of depression.
• There is interindividual variability in response to available antidepressants and no way to predict which drug will be effective in
a particular patient.
• Psychological therapies are first-line treatment in children with depression. Only consider using pharmacotherapy for major
depression in children within the context of a comprehensive management plan.
• During pregnancy, there is a need to balance reducing the psychotropic effects of medicines on the fetus with the impact of
poorly controlled depression on the fetus.
• Sertraline is the most commonly used SSRI in pregnancy because it has the most safety data.
• Paroxetine has been associated with fetal heart defects and should not be started during pregnancy.
• Of all SSRIs, fluoxetine has the highest reported concentrations in breastmilk.
• Older people are more sensitive to the adverse effects of antidepressants and often need more gradual dose titration and lower
doses.

12. Which ONE of the following statements is FALSE about 14. Which of the following statements is TRUE? In patients
mild major depression? with depression who are pregnant:
a) Psychological therapies are preferred; a) Reducing psychotropic effects on the fetus is
antidepressants are not routinely recommended important; it is equally important not to undertreat
but can be used if psychological therapies are not depression during pregnancy because of increased
available or based on patient preference. risk of suicide and other adverse obstetric and
neonatal outcomes.
b) Psychosocial interventions have an important role
to play. b) Psychological therapies are not recommended due
to the need for a fast resolution of symptoms.
c) If mild major depression presents during pregnancy,
start a SSRI other than paroxetine (sertraline is most c) Sertraline should be avoided because it has the least
commonly used) and avoid starting fluoxetine. safety data of all of the selective serotonin reuptake
inhibitors (SSRIs).
d) Consider starting an antidepressant in an older
person with mild depression who has not responded d) Fluoxetine is the selective serotonin reuptake
to non-pharmacological therapies. inhibitor (SSRI) of choice.
13. Which ONE of the following treatment options is NOT 15. Which ONE of the following treatment options should
normally considered for mild to moderate depression be considered for ALL forms of depression?
in children over 6 years?
a) Psychological therapies.
a) Psychological therapies. b) Selective serotonin reuptake inhibitors (SSRIs).
b) Lifestyle changes such as sleep hygiene and exercise, c) Electroconvulsive therapy (ECT).
as well as addressing factors that may contribute to
their disorder, which can include family conflict or d) Tricyclic antidepressants (TCAs).
parental mental health issues.
16. Which ONE of the following statements is TRUE when
c) Initiating a therapeutic dose of escitalopram treating an older person with depression with a SSRI?
together with cognitive behavioural therapy.
a) Careful of monitoring of electrolytes is required due
d) Psychoeducation.
to the risk of hypokalaemia.
b) Falls and fracture risk is increased, especially when
combined with other psychotropics.
c) Up-titration of doses can occur rapidly as older
people often can tolerate the adverse effects, such
as gastrointestinal disturbance, increased arousal,
anxiety or sleep disturbance.
d) Always consider co-prescribing with mirtazapine to
reduce insomnia.

Section 4. Management
Although depression is a chronic, often lifelong, illness, resilience

Learning objectives against depression can be enhanced by positive lifestyle ‘actions’
such as sleep management, exercise and a healthy diet, as well
• Discuss the goals of treatment for depressive disorders.
as addressing negative habits such as smoking and substance
• Identify non-pharmacological strategies for the
misuse. These ‘actions’ are key to laying down a foundation for
management of depressive disorders. the management of depression and should be implemented
• Describe the factors that influence the choice of as comprehensively as possible. In addition to lifestyle actions,
antidepressant for the management of depressive treatment options for reducing symptoms in depression include
disorders. psychoeducation, psychosocial interventions, psychological
• Identify strategies to optimise antidepressant use. or talking therapies, pharmacotherapy (e.g. antidepressants),
psychosocial therapy (e.g. facilitated self-help based on CBT
principles, exercise groups, group-based peer support program)
or physical therapy such as electroconvulsive therapy (ECT).

Goals of treatment Diet
Depression is a chronic illness and while treatments are available There is some evidence supporting the benefits of the
to manage acute episodes, a patient’s underlying vulnerability Mediterranean diet (characterised by high vegetable, fruit,
is unlikely to be rectified.5 As such, the goals of treatments fish and grain components, and low animal fat components)
include restoring mood, eradicating symptoms, improving daily in depressive disorders.5 Additionally, diets with high levels of
functioning and quality of life, increasing resilience, reducing processed foods have been found to contribute to depressive
suicidality and preventing relapse.5,11 symptoms. Depression can influence eating habits. For example,
patients with depression may limit their eating or overeat in
response to their symptoms. Pharmacists can provide advice
Psychoeducation about the importance of a healthy and balanced diet. It can be
helpful to enquire about patients’ specific eating habits and
References
Psychoeducation should be provided when a patient is first
diagnosed with depression. It has a number of benefits including address any issues that may be contributing to their mental
reducing relapse severity and frequency, improving treatment health issues.1 It is important to be mindful of the socioeconomic
adherence and quality of life and lowering self-stigma. It involves challenges that play a role in a person’s ability to make healthy
educating the patient and their family, carers and significant decisions about the diet they consume. A healthy diet has the
others about the diagnosis, including: causes, symptoms, components outlined in Box 2 below.
treatment options, course of the illness and possible outcomes, Box 2. Components of a healthy diet
alleviating and aggravating factors and how and where to seek
• Ample amounts of fruits, vegetables (including potatoes),
treatment, when to contact a doctor (e.g. increased suicidal
thoughts), supports available, clearing myths about the illness breads (particularly whole grain), nuts and seeds.
(e.g. it is not a sign of weakness), early signs of relapse to look out • Fresh rather than processed food.
for and lifestyle tips to improve outcomes.1,65 • Fresh fruits as preferred desserts.
• Dairy, poultry and fish in moderate quantities.
Non-pharmacological management • Red meats in small amounts. Reduce saturated fats.

• Olive oil (or other vegetable oil if preferred) as prime
source of dietary fat.
Lifestyle changes
• Alcohol in modest quantities: maximum 1–2 standard
Lifestyle changes are foundational in the treatment of drinks per day for males and 1 for females.
depression. They include improving sleep hygiene, instituting
exercise and a healthy diet, smoking cessation, and limiting
Adapted from: Malhi5
alcohol and recreational substance use. Educating and
supporting patients with depression to make these lifestyle Exercise
changes can have a positive impact on their symptoms.1,65
Regular exercise is associated with improved sleep, mood and
Sleep hygiene quality of life, and enhances the effects of antidepressants in
depressive disorders.5 The motivational challenges of developing
Given the increasing recognition that circadian function is both
and maintaining an exercise plan are well known for the general
a risk factor for depressive disorders and an intervention target,
population and are magnified in people with depression.
there is growing interest in depressive disorder interventions
Pharmacists can reinforce the strategies in Box 3 to support a
targeting circadian pathways and/or changes in sleep.5
person with depression in developing a healthy exercise plan.
Instituting good sleep hygiene is important for patients with
depression to help restore a normal sleep pattern and improve
sleep quality.5 Good sleep hygiene is about being in the best
position to sleep well each night by optimising sleep schedule,
pre-bed and daily routines, as well as creating a pleasant
bedroom environment. There are a large number of sleep
hygiene strategies. Some of the key strategies include exercising
regularly (but not within four hours of bedtime), maintaining a
regular sleep–wake cycle, avoiding alcohol, caffeine and nicotine
consumption for four to six hours before bedtime, avoiding
daytime naps, practicing relaxation techniques throughout
the day and avoiding stimulating activities in the bedroom
(e.g. watching TV, using the phone, working).66 The Australian
Pharmaceutical Formulary and Handbook (APF) digital provides
a more detailed list of sleep hygiene strategies. This can be
accessed at apf.psa.org.au/non-prescription-medicine-guides/
insomnia/insomnia. These strategies can be adapted to fit into an
individual’s circumstances to help create an individualised sleep
hygiene checklist to enable the best sleep possible.

Box 3. Strategies to support people with depression information on helping someone with a mental illness to quit
developing a healthy exercise plan smoking can be found at www.health.gov.au/sites/default/files/
supporting-someone-with-a-mental-illness-to-quit-smoking.pdf.
• Inform the patient that exercise is a helpful adjunctive
treatment for depressive disorders because it improves Alcohol and substance misuse
brain function, offers pleasurable experiences, improves
Alcohol and substance misuse problems are common in the
self-esteem, enhances sleep quality, and increases the
community and are often a hidden contributing factor to
opportunities for interactions with other people.
depression and poor treatment response. Interdisciplinary
• Daily exercise is preferred over intermittent activity.
approaches are needed to address alcohol and substance misuse
• Aerobic (e.g. walking, running, cycling) and resistance and pharmacists can play a key role in providing high quality
exercise (e.g. using weights) are both effective for information and reinforcing strategies to reduce misuse.
depressive disorders, and the combination may be better
than either alone. Psychosocial interventions
• Some patients may find exercising with other people more
motivating, but this is not universally the case. Psychosocial interventions can be defined as “interpersonal or
informational activities, techniques, or strategies that target
• It is important to choose the form of exercise according to
biological, behavioural, cognitive, emotional, interpersonal,
personal preference; previous preferences may help with
social, or environmental factors with the aim of improving
this choice.
health functioning and well-being”.69 The range of psychosocial
• Ideally, the exercise should be pleasurable and require
interventions is wide and varied and includes strategies
some effort, but not be exhausting or painful.
such as behavioural interventions, skills training (problem
• Documenting an exercise plan is helpful, along with
solving, anger management, social skills, stress management,
regular reviews of progress and difficulties. parenting skills), relaxation strategies (including any activities
• Some patients with depressive disorders struggle to find the patient finds relaxing such as listening to music, and formal
the ‘right exercise’ for them. Suggestions based upon their relaxation activities such as meditation, mindfulness and yoga),
past activities and a review of options (e.g. start with a interpersonal therapy, psychoeducation, peer support and social
walk every day, perhaps with another person or pet) may justice. Psychosocial interventions can be delivered by a range
be helpful. of health professions with social workers and occupational
• Patients will benefit from building on their exercise plans therapists having an important role to play in implementing
to make these activities part of their daily lives. This may these strategies.
start as ‘treatment’ but could progress to becoming a
‘lifestyle’. Psychological therapies
Adapted from: Malhi⁵ A number of psychological therapies are available for the
treatment of depression. Research into the effectiveness of
Smoking cessation psychological therapies continues to grow and a number
of therapies have been found to be effective for reducing
Cigarette smoking rates in people with depression are higher
symptoms of depression.5,11 The 2020 Royal Australian and New
than the general population.5 These high rates represent
Zealand College of Psychiatrists clinical practice guidelines for
a significant public health concern and account for some
mood disorders list six therapies that have now been found to be
of the reduced life expectancy associated with psychiatric
more effective than wait-list control. These are outlined below.
illness.67 Smoking may also interfere with the metabolism of
It is important to note that these should only be delivered by
antidepressant and antipsychotic medications as cigarette
appropriately qualified professionals with specific training in
smoking induces the cytochrome P450 enzyme CYP1A2.
the therapeutic approach, such as a clinical psychologist or
Evidence for the direction of association between cigarette
psychiatrist. Pharmacists can reinforce the importance of these
smoking and psychiatric illness is inconclusive (i.e. whether
therapies to patients who have been recommended them by a
people with depression self-medicate with cigarette smoking or
mental health care practitioner.
whether smoking leads to depression).67 Nicotine is addictive and
associated with withdrawal symptoms including depression and Cognitive behavioural therapy (CBT) – Focuses on helping
anxiety. These can be more intense in people with psychiatric patients to identify unhelpful or distorted thoughts, emotions
illness.68 Nonetheless, smoking cessation is recommended for and behaviours, and teaching patients strategies to view
people with depression to improve both their physical and challenging situations more clearly and respond to these
mental health. Pharmacists can provide tips and support to help thoughts, emotions and behaviours in a more effective way.1
patients quit, advice on nicotine replacement therapy, and advice Interpersonal therapy (IPT) – Focuses on helping patients
on prescription medications for smoking cessation, as well as to identify and understand interpersonal problems that could
referral to smoking cessation support services. be contributing to their condition and helping patients to
Beyond Blue has a patient information booklet Depression and implement strategies to improve their interpersonal functioning,
quitting smoking, which can be accessed at www.beyondblue. focusing on the areas of grief, interpersonal disputes and deficits
org.au/docs/default-source/resources/bl0886-depression-and- and role transitions.1
quitting-smoking-booklet_lr.pdf?sfvrsn=7c1946eb_2. Further

Problem solving therapy – Focuses on helping the patient
to articulate personal problems, working with the patient to
Pharmacological management
develop multiple solutions for each problem and then helping
the patient to systematically select, implement and evaluate the
Choice of antidepressant therapy for major
solutions.5 This therapy aims to provide patients with the skills depression
and confidence to solve problems themselves, as opposed to the The approach to initial antidepressant therapy for major
clinician determining solutions and providing directions.5 depression varies between guidelines. While the efficacy of
Behavioural activation therapy – Focuses on assisting currently available antidepressants have been shown to be
patients to reconnect with sources of positive reinforcement by similar, there are some differences in tolerability.71 In addition,
scheduling activities to increase pleasant activities and positive there is interindividual variation in response to antidepressants
interactions such as physical and social activity.5 that cannot be predicted.1 If an antidepressant is indicated, initial
choice should be guided by the following factors1,72:
Nondirective supportive therapy – Sometimes referred
to as counselling. Focuses on providing the patient with an • Medicines’ adverse effects profile – The short- and long-term
opportunity to freely and openly discuss concerns and receive adverse effects profile and frequency of adverse effects of
empathy.5 individual medicines should be considered.
Short-term psychodynamic therapy – Focuses on helping • Potential for drug interactions – The patient’s other medicines
the patient to understand repetitive internal struggles and should be considered to avoid potential drug interactions (e.g.
interpersonal conflicts by exploring past experiences and increased risk of serotonin toxicity when SSRIs are taken with
conflicts, as well identifying patterns in actions, thoughts, tramadol).
feelings and relationships.1,5 • Patient’s comorbidities – May impact the pharmacodynamics
or pharmacokinetics of antidepressants (e.g. liver disease,
Psychological therapies can be delivered individually, as part of a
cognitive impairment).
group, online or face-to-face.1
• Safety in overdose – SSRIs are less lethal in overdose compared
There is increasing evidence for and availability of online to TCAs.
therapies for the treatment of depression. To date, the majority of • Depression symptomology – There are some differences in
the research in this area has focused on internet-based cognitive the symptoms antidepressants target. The symptoms targeted
behavioural therapy. Online therapies can be clinician supported should be matched to the patient’s clinical presentation.
or patient led. Online therapies have different strengths and In addition, adverse effects of some antidepressants can
weaknesses relative to face-to-face therapy and can have an actually be beneficial for certain symptoms of depression (e.g.
important role to play in the treatment of depression. However, sedation caused by mirtazapine can be useful for patients
they are not suitable for all patients and best recommended by with insomnia, weight gain associated with mirtazapine can
someone with expertise in the area after the patient has been be useful for patients with significant weight loss due to
comprehensively assessed. depression).
• Patient’s age – Older patients are more likely to have
Physical treatments comorbidities and may be more sensitive to adverse effects
of antidepressants. Young people are more susceptible to
Electroconvulsive therapy developing activation and suicidal thoughts when starting
treatment with an antidepressant (paroxetine should be
Electroconvulsive therapy (ECT) is a procedure carried out under avoided as it has been associated with increased risk of suicidal
general anaesthesia in which an electric current is administered thoughts).
to the brain to induce a seizure.1 Exactly how ECT works is not • Cost – Certain medications used to treat depression are not
yet fully understood. However, the seizure affects the entire covered by the PBS and may lead to affordability issues and
brain, including parts that control mood, appetite and sleep, thus to non-adherence. The additional cost of medications
and causes chemical and cellular changes in the brain that can may also contribute to financial stressors that some patients
rapidly relieve symptoms of depression.1,70 It can be used for are already facing.
patients with severe depression who require rapid treatment • Ease of dosing – Patients are more likely to adhere to a once-a-
response (e.g. risk of suicide, malnutrition, dehydration, psychotic
day dosing regimen compared to multiple doses throughout
depression and catatonia). It can also be used for patients who
the day.
have severe treatment-resistant major depression.5
• Withdrawal symptoms – Some patients are more prone
to abrupt cessation of medications (e.g. poor cognition,
Transcranial magnetic stimulation comorbid drug and alcohol use). Selecting an antidepressant
Transcranial magnetic stimulation (TMS) is a non-invasive with mild or no withdrawal symptoms is ideal in this cohort of
procedure that uses a rapidly changing magnetic field to induce patients.
weak electric currents in the cerebral cortex and stimulate • Whether the patient is planning pregnancy or is pregnant
nerve cells to improve symptoms of depression.1 It can be used or breastfeeding – If the patient is planning pregnancy or
for patients with major depression who have been resistant to breastfeeding, it would be ideal to select a medication safe for
antidepressants or who have only had a partial response.1 It is pregnancy and breastfeeding so the patient can continue the
less effective than ECT for more severe cases of depression.1 treatment during this period.

• Patient preference – Adherence is improved if the patient is TCAs are associated with a higher burden of adverse effects than
involved in the decision about the choice of antidepressant, SSRIs or SNRIs, including anticholinergic side effects, dizziness,
including a discussion of the expected benefits and potential sedation and sweating. Toxicity in overdose is also higher with
adverse effects. Acceptability of different side effects varies TCAs. For these reasons, TCAs are generally reserved for use after
between patients. a poor response or tolerability problems from initial treatment
The pharmacological profiles of the antidepressants available with an SSRI or SNRI, or where there has been a good previous
in Australia are presented in Table 5. Note that bupropion is response with a TCA.
only registered in Australia for smoking cessation, although it Irreversible MAOIs such as tranylcypromine and phenelzine (only
is included in treatment guidelines elsewhere, particularly from available via Special Access Scheme (SAS) or compounded) are
North America. Both agomelatine and vortioxetine are available effective in treating depression, but they are not used frequently
in Australia but are not listed on the Pharmaceutical Benefits because they have a high burden of side effects (e.g. postural
Scheme (PBS). hypotension, insomnia, dizziness, sexual dysfunction, weight
Selective serotonin reuptake inhibitors (SSRIs) and serotonin gain, headache), are potentially fatal in overdose, and patients
and norepinephrine reuptake inhibitors (SNRIs) are generally face concomitant dietary restrictions. Therefore, they should
considered to be first-line medicines in both short- and long- be reserved for people who have not responded to, or who are
term treatment of depression.1 SSRIs and SNRIs are commonly intolerant of, other treatment approaches. Moclobemide is a
prescribed and are generally well tolerated. They are also safer in reversible inhibitor of monoamine oxidase (selective for type A),
overdose and easier to use than older classes of antidepressants which reduces the need for dietary restrictions.
such as tricyclic antidepressants (TCAs) and monoamine Reboxetine inhibits noradrenaline reuptake and weakly
oxidase inhibitors (MAOIs). However, both SSRIs and SNRIs inhibits serotonin reuptake. Adverse effects can include dry
have potentially troublesome adverse effects such as increased mouth, constipation, urinary retention, sweating, insomnia,
anxiety, insomnia, nausea, and sexual dysfunction. They can also increased blood pressure, heart rate and headache. Efficacy
cause discontinuation symptoms, particularly if they are stopped data for reboxetine is conflicting and some clinicians view this
abruptly. Venlafaxine and desvenlafaxine have been associated antidepressant as less effective than other antidepressants.74
with an increase in blood pressure; blood pressure monitoring
is recommended before starting these medicines and then Drug interactions
regularly while taking them.73
Drug interactions can be pharmacodynamic, where one
Mirtazapine and mianserin are both tetracyclic antidepressants.
medicine alters the pharmacological response of another
Mirtazapine is generally considered to be a first-line medicine
(e.g. augmented anticholinergic effects) or pharmacokinetic,
for depression.1 It is unlikely to cause the commonly reported
where one medicine alters the plasma level of another, and
side effects associated with other antidepressants such as sexual
when medicines are combined either or both of these types of
dysfunction, nausea, agitation and anxiety, but is associated
interactions many occur. This Essential CPE does not provide a
with significant sedation, peripheral oedema and increased
complete review of all drug interactions, safety considerations
appetite, which can result in marked weight gain. Its sedative
or adverse effects of antidepressants. Pharmacists should always
effects can be beneficial for patients who are also experiencing
consult an appropriate reference book such as the current
sleep disturbance or insomnia. Its effect on appetite and weight
version of the Australian Medicines Handbook (AMH), Stockley’s
gain can be beneficial for patients experiencing reduced
Drug Interactions, and the registered product information for
appetite and/or weight loss as symptoms of their depression.
individual medicines. Medicines Information Service pharmacists
Mianserin is less commonly used. It resembles TCAs with lower
based in hospital settings may also be able to provide specific
anticholinergic and cardiovascular adverse effects and a lower
advice.
toxicity risk in overdose. However, it can cause neutropenia,
which has resulted in fatal agranulocytosis and hence a full blood In general, TCAs and irreversible MAOIs have the greatest drug
count is required prior to starting, with ongoing monitoring interaction potential because of their wide, nonselective receptor
throughout treatment.73 profiles and, in the case of MAOIs, their irreversible MAO enzyme
blockade. MAOIs also interact with a wide variety of food and
Agomelatine is generally well tolerated and less likely than
other medicines (Box 4), including other antidepressants, and
SSRIs or SNRIs to cause sexual dysfunction or discontinuation
these interactions can be fatal.75
symptoms and may be considered when other antidepressants
are not tolerated, or the response is inadequate. Agomelatine A key pharmacodynamic interaction highlighted here is
can cause elevation of liver enzymes; therefore, monitoring of serotonin toxicity. Serotonin toxicity encompasses a spectrum
liver function tests prior to, and in the six months after starting, is of symptoms and can range in intensity from mild symptoms
required.73 to, in severe cases, coma and death (Box 5). This can occur
when serotonergic medicines are combined or when switching
Vortioxetine is a serotonin transporter blocker that appears
antidepressant, and can also be an adverse effect from a high
to be well tolerated. However, nausea is common and sexual
dose of a single drug.
dysfunction emerges at higher doses. It seems to have a low risk of
withdrawal symptoms and gradual reduction in dose is not always Antidepressants also have the potential to cause
required when stopping treatment.73 Vortioxetine may have pharmacokinetic interactions via the cytochrome P450 system.
beneficial effects on cognitive functioning and can be beneficial A pharmacokinetic interaction occurs if a medicine inhibits
for patients with cognitive difficulties, including older patients.5 (or induces) the enzyme when co-prescribed with a medicine

Table 5. Antidepressant pharmacological profiles
Mechanism of Adverse effect Hepatic Overdose

action a enzyme lethality
Anticholinergic Sedation Insomnia/ Postural Nausea/ Sexual Weight Specific adverse effects
agitation hypotension gastro dysfunction gain inhibition
intestinal
Tricyclic antidepressants (TCAs)
clomipramine SRI+NRI ++ ++ + ++ + ++ + − Moderate
amitriptyline, dosulepin NRI>SRI ++ ++ − ++ − + ++ − High
doxepin
imipramine NRI>SRI ++ + + ++ − + + − High
nortriptyline NRI + + + + − + − − High
Selective serotonin reuptake inhibitors (SSRIs)
citalopram, SRI − − + − ++ ++ − − Low
escitlopram,
sertraline
fluoxetine, fluvoxamine, SRI − − + − ++ ++ − ++ Low
paroxetine
Other reuptake inhibitors
reboxetine NRI + − + − − + − − Low
venlafaxine, desvenlafaxine SRI>NRI − − + − ++ ++ − Hypertension, sweating + Moderate
duloxetine SRI+NRI − − + − ++ ++ − − ? Low
b
bupropion ?DRI+NRI − − + − − − − Seizure potential − ? Moderate
Receptor antagonists
mianserin 5-HT2 + α1 + α2 + ++ − − − − − ? Low
mirtazapine 5-HT2 +5-HT3 + α2 − ++ − − − − ++ − Low
Monoamine oxidase inhibitors (MAOIs)
Essential CPE – Depression I © Pharmaceutical Society of Australia Ltd.

phenelzine and Irreversible + + ++ ++ + ++ ++ Hypertensive crisis with ? High
tranylcypromine sympathomimetics,
oedema
moclobemide RIMA − − + − + − − − Low
Other
agomelatine c M + 5-HT2C − + + − + − − Requires LFT monitoring − ?
vortioxetine c SRI + 5-HT3 + − − − − ++ +/- − − ?

5-HT7 + 5-HT1B +
5-HT1A
NRI = noradrenaline reuptake inhibitor; SRI = serotonin reuptake inhibitor; DRI = dopamine reuptake inhibitor; 5-HT1A = 5-HT1A agonist; 5-HT1B = 5-HT1B partial agonist; 5-HT2/5-HT2C = 5-HT2/5-HT2C antagonist; 5-HT3 = 5-HT3 antagonist; 5-HT⁷ = 5-HT7 antagonist;
α1/α2 = α1 antagonist/α2 antagonist; M = melatonin agonist; RIMA = reversible inhibitor of monoamine oxidase type A
++ relatively common or strong; + may occur or moderately strong; – absent or rare/weak;? unknown/insufficient information
a
side effects commonly caused by muscarinic receptor blockade including dry mouth, sweating, blurred vision, constipation and urinary retention; however may be caused by other mechanisms and does not necessarily imply that the drug binds to muscarinic
receptors; b Registered in Australia for smoking cessation; c Not funded on PBS in Australia
Note: These side effect profiles are not comprehensive, have been compiled from various sources, and are for rough comparisons only. Refer to individual Medicine Data Sheets.
27
Reference: Adapted from Cleare8
Box 4. Food/drink and drug interactions with MAOIs that is a substrate for the same enzyme. Antidepressants
have different effects on the cytochrome P450 enzymes. For
3 MAOIs block monoamine oxidase, an enzyme that breaks example, citalopram, escitalopram, sertraline, venlafaxine,
down excess tyramine in the body. Eating high-tyramine reboxetine, and mirtazapine have a low risk of pharmacokinetic
foods when taking a MAOI can cause tyramine levels to interactions; duloxetine and bupropion are moderate inhibitors
increase to toxic levels, which can cause a dangerous rise in of cytochrome enzymes; and fluoxetine, fluvoxamine and
blood pressure. paroxetine can strongly inhibit one or more cytochrome P450
Foods/drinks that contain tyramine include: matured or aged enzymes.76 Pharmacists should always refer to the current version
cheese, matured or aged meat (e.g. salami), liver products, of the AMH or APF for a full list of medicines that are substrates
sauerkraut, certain alcoholic drinks, yeast extracts (e.g. for, or inhibitors of, the cytochrome P450 system.
Vegemite), soy bean products (e.g. soy sauce, miso, tofu),
banana peel (e.g. used as flavouring in banana chips). Optimising antidepressant use
Key medicine interactions with MAOIs: Once antidepressant treatment has been started, it is important
• May increase the effects of adrenaline, dopamine, patients are supported over the first two months of acute
noradrenaline and zolmitriptan. treatment as this is a key time to follow up and monitor for
• May increase the risk of adverse effects and should be effective response, suicide risk, tolerability and adverse effects,
and adherence issues.
used with caution with selegiline.
• Contraindicated due to potentially serious reactions with For some antidepressants, such as SSRIs, an effective dose can be
atomoxetine, dexamphetamine, dextromethorphan, prescribed from the beginning of treatment. In comparison, in
entacapone, ephedrine, fentanyl, methylphenidate, order to avoid side effects, TCAs typically require dose titration
linezolid, pethidine, phentermine, phenylephrine, every three to seven days to a recommended target dose, if
pseudoephedrine, reboxetine, SNRIs, SSRIs, tramadol, tolerated.
TCAs. Most people seem to experience a delay of about two weeks
References: Psychotropic Expert Group , Rossi
1 73 before they can sense any improvement in their symptoms and
the response time may be longer for older people. However, lack
Box 5. Serotonin toxicity of significant improvement after two to four weeks of treatment
at a therapeutic dose is likely to indicate a lack of sustained
Symptoms of serotonin toxicity include: response to the selected antidepressant and next-step treatment
• Cardiovascular: tachycardia, hypertension. should be considered.
• Gastrointestinal: abdominal cramping, diarrhoea. As previously mentioned, all antidepressants are associated with
• Neurological: tremor, muscle spasms, convulsions, poor adverse effects. Although some may improve over time (e.g.
speech, incoordination. nausea and increased anxiety with SSRI use), sexual dysfunction
• Psychiatric: manic-like symptoms, agitation, racing with SSRIs and SNRIs, and anticholinergic side effects from TCAs
thoughts, hurried speech, elevated or dysphoric mood, often persist and can be distressing, especially in longer-term
confusion. treatment. Transient adverse effects can often be managed
• Other: sweating, shivering, coma, death. by patients, providing they receive adequate explanations;
reassurance and monitoring by the pharmacist is important.
Medicines that can contribute to serotonin toxicity include:
Dose reduction, slower titration, switching antidepressants to
Antidepressants MAOIs, moclobemide, SNRIs, some one with less tendency to cause troublesome adverse effects,
TCAs non-pharmacological management (e.g. exercise and diet to
Complementary St John’s wort prevent weight gain), or symptomatic treatment with another
medicines medicine (e.g. short-term benzodiazepines for insomnia,
agitation/nervousness) may also be required to manage adverse
Opioids Dextromethorphan, fentanyl, effects and maintain improvement.
pethidine, tramadol
Adherence to antidepressant medicines is essential to ensure
Other drugs Triptans, tryptophan, methylene blue, their effectiveness. Poor adherence to antidepressants is
phentermine, lithium, linezolid, and common and can be associated with non-response to treatment,
illicit drugs such as LSD or ecstasy. relapse and increased morbidity, comorbidity and mortality.
Poor adherence can include patients not taking their medicine
Reference: Rossi73
as prescribed, or discontinuing them prematurely. The reasons
for this include adverse effects, insufficient education about the
medicine, misperceptions about antidepressants, lack of patient
involvement in decision making and cost. Pharmacists are able
to identify adherence issues and support the patient through
the provision of education and implementation of strategies to
improve adherence.77

Key points
• Goals for the treatment of depression include restoring mood, eradicating symptoms, improving daily functioning and quality of
life, increasing resilience, reducing suicidality and preventing relapse.
• Lifestyle changes, including improving sleep hygiene and diet, increasing exercise, smoking cessation and reducing alcohol and
substance misuse, are fundamental to the treatment of depression.
• Shared decision making with the patient is critical if an antidepressant is prescribed. The choice of antidepressant depends on its
efficacy and tolerability, the depressive presentation, patient preference and drug interactions.
• Older adults are more likely to have multiple comorbidities and are more sensitive to antidepressant adverse effects
(e.g. hyponatraemia with SSRIs), which may limit the choice of antidepressant. Older adults are also more likely to have
polypharmacy; if possible, antidepressants with less interaction potential, such as citalopram and sertraline, should be used.
• Although some adverse effects of antidepressants may improve over time (e.g. nausea and increased anxiety with SSRI use),
other adverse effects such as sexual dysfunction with SSRIs and SNRIs, and anticholinergic side effects from TCAs often persist
and can be distressing, especially in longer-term treatment.
• Common concerns people have about antidepressant medicines relate to adverse effects and dependence. Dependence
concerns include inability to cope without medicines, developing tolerance to treatments and withdrawal symptoms.
• Poor adherence to antidepressants is common; education on the condition and medicine as well as patient involvement in
decision making can help to improve adherence.

17. When providing counselling to a 32-year-old man 20. After a 2-week trial of an antidepressant, such as
prescribed duloxetine, which ONE of the key points is sertraline 50 mg, in a 22-year-old female with very little
most appropriate to discuss? response, which ONE of the following pathways is NOT
consistent with best practice?
a) Advise that they may experience gastrointestinal
disturbance, mild anxiety and insomnia, and that the a) Suggest that they continue with sertraline for
medicine may not improve their mood immediately. another 2 weeks to see if there is a response.
b) Advise that sexual dysfunction is very common b) Reinforce the importance of lifestyle changes such
and encourage them to ask their GP to prescribe as sleep hygiene, exercise, reducing alcohol and
sildenafil. smoking (if appropriate).
c) Ensure they have an emergency safety plan as c) If it has not already commenced, encourage her to
duloxetine commonly increases suicidal ideation. commence cognitive behavioural therapy.
d) Highlight that serotonin and norepinephrine d) Advise that a swap to another agent is needed and
reuptake inhibitors (SNRIs) can cause serotonin recommend a change to moclobemide after a 2
toxicity, which is life threatening. week wash out.
18. Which ONE of the following antidepressants is most 21. Which ONE of the following is NOT a goal of treatment
likely to cause sexual dysfunction? for depressive disorders?
a) paroxetine. a) Improving ability to carry out usual activities.
b) moclobemide. b) Reducing fluctuations in mood.
c) reboxetine. c) Reducing suicidality.
d) mirtazapine. d) Preventing relapse.
19. Which ONE of the following antidepressants is 22. Lifestyle changes are foundational in the treatment of
LEAST likely to inhibit one or more cytochrome P450 depression. Which ONE of the following is CORRECT?
enzymes?
a) A healthy diet for people with depression should
a) fluoxetine. include plenty of fruit and vegetables, fresh rather
b) paroxetine. than processed food and limited carbohydrates.
c) fluvoxamine. b) Regular exercise can augment the effects of
antidepressants in people with depression.
d) citalopram.
c) Smoking cessation should be avoided in a patient
being treated for depression as anxiety and
depression are possible withdrawal symptoms.
d) Exercising immediately prior to bedtime can help to
improve sleep quality.

Section 5. Follow-up and monitoring
Learning objectives Follow-up and monitoring

Follow-up review should occur every one to two weeks once
• Discuss risk factors for and management of relapse.
antidepressant therapy has commenced. Pharmacists can gauge
• Identify strategies to manage inadequate response to a patient’s response by checking in and asking how they are
antidepressant therapy. going with the medicine when they have their prescription
• Discuss management of treatment-resistant depression. refilled, especially during the initial period. Whilst information
about depression and specific medicines may have been
provided early on in the therapeutic encounter, when patients
are in the pharmacy having their prescription refilled it can be a
good time to provide reassurance and counselling and answer
any outstanding queries the patient may have. Refill intervals
and quantities of rescue medicines for depression, such as
benzodiazepines, can also give an indication of how the patient
is going. In addition, pharmacists have an important role to play
in monitoring adherence through checking prescription refill
intervals.

Relapse Inadequate response
After an episode of depression, there is a high risk of relapse over If a patient does not respond adequately to antidepressant
the next six months. The risk declines with time in remission. therapy after an appropriate trial, a number of factors should be
People should continue on the same treatment they have considered, including whether the diagnosis is correct, if there
responded to (at the same dose) for six to 12 months after are any medical causes that have not been identified, whether
remission if this is their first episode and they have a low risk of comorbidities, alcohol and substance abuse problems and
relapse.1 During remission of major depression, it is important psychosocial factors have been addressed, whether the patient
to identify and address factors that increase the risk of recurrent has been adherent, and if there are any drug interactions that
episodes, if possible (Box 6). could be affecting the response.
Box 6. Factors that increase the risk of recurrent episodes of The ideal outcome when using antidepressant medicines is
major depression a treatment response within a timeframe of four to six weeks
for depression. There is some debate about when to consider
• Non-adherence to previous treatment alternative therapies, but the general consensus is that the
• Presence of residual symptoms likelihood of a sustained response to an antidepressant is low
• Number of previous episodes when there is a lack of benefit at two to four weeks. If there has
• Severity and duration of the most recent episode been some improvement at this time, then the dosage should
be reassessed and treatment continued for another four weeks
• Degree of treatment resistance
before further assessment. If there is minimal improvement at
• Insomnia
this time, then next-step treatment should be considered.
• Illicit substance use
One option for individuals who have had a poor response to
• Employment difficulties
first-line treatments is an increase in dose; this can be considered
• Comorbidities (anxiety disorder, personality disorder,
if the individual has not experienced marked adverse effects and
medical condition – especially for older people)
there has been some improvement noted on the lower dose.
• Lack of support network
Another option is switching antidepressants. This can be
• Stress (work/life/social)
considered when side effects are problematic and there has
• Female gender
been no improvement.78 Switching antidepressants needs to be
Reference: Psychotropic Expert Group1 done with caution due to the risk of drug interactions, serotonin
syndrome, withdrawal symptoms or relapse.11 A number of
Educate patients and family, carers or significant others about strategies can be used for switching between antidepressants.
how to identify early warning signs of a recurrent episode and Close monitoring and caution is always required as patients can
develop a plan for early intervention. Most patients who have respond idiosyncratically and serious complications can occur.78
had an episode of major depression will experience more than A number of guidelines are available for switching between
one episode in their lifetime. antidepressants, including The Australian Medicines Handbook
If a patient relapses after having achieved full remission, it is antidepressant changeover guide and the NPS MedicineWise’s
known as a recurrent episode. If the patient is not taking an Switching and stopping antidepressants article available at
antidepressant when their depression recurs, they should www.nps.org.au/australian-prescriber/articles/switching-and-
be restarted on the antidepressant that had previously led stopping-antidepressants.
to remission.1 If the patient is on an antidepressant when
recurrence occurs, treatment can involve increasing the dose Treatment-resistant depression
of the antidepressant (if appropriate) or trialling a different
If a patient has trialled an effective dose of at least two
antidepressant.1 If two or more antidepressants have been
antidepressants as monotherapy for an adequate trial period
trialled, then the patient should be treated for treatment-
they are considered to have treatment-resistant depression.1
resistant major depression.1 If a patient has had three or
These patients should be referred to a psychiatrist.
more episodes in total, or at least two episodes over a five
year period, then longer term antidepressant therapy (3–5 The choice of therapy for treatment-resistant depression is
years, or sometimes lifelong) can be required.1 Psychological influenced by individual patient factors (such as severity of
therapies also have a role to play in reducing the risk of relapse. depression and comorbidities) and the availability of treatments.
Augmentation of treatment with lithium and ECT can also play The following approaches may be considered by a psychiatrist:
a role in the management of patients who experience recurrent Dose increase – Many antidepressants have relatively flat dose-
depressive episodes; these usually require specialist input. response curves so increasing doses beyond recommended
standard doses may not improve symptoms; however, for some
antidepressants it may improve the response.5 Further, drug
metabolism can vary due to differing patient genetics and drug
interactions. For these reasons, there are some situations where
patients may be prescribed doses above the recommended
range. However, there is also an increased risk of side effects and
this is usually only done after carefully weighing up the potential
benefits and harms.1,5

Antidepressant augmentation – Antidepressant therapy can be
augmented by the addition of another medicine such as lithium,
Stopping antidepressant treatment
liothyronine (T3), antipsychotics (e.g. aripiprazole, brexpiprazole, Stopping certain antidepressants abruptly can result in
olanzapine and quetiapine), intranasal esketamine (discussed in unpleasant withdrawal symptoms.78 Depending on the
more detail below) or an antidepressant from a different class.1,79 characteristics of the particular medicine, withdrawal symptoms
There is also emerging evidence for the use of stimulants to generally begin within hours to days of dose reduction.
augment antidepressant therapy in treatment-resistant patients.5 Withdrawal symptoms are usually mild and only last a couple of
Augmentation can provide faster, complimentary or synergistic weeks, but sometimes they can persist for longer and interfere
effects compared to switching antidepressants and can avoid with a patient’s functioning.
withdrawal symptoms.79 The specific withdrawal effects and the severity of the effects
Medicines – Irreversible nonselective MAOIs (e.g. vary between different classes of antidepressants as well as
tranylcypromine), mianserin or TCAs (e.g. nortriptyline) may between individual antidepressants within classes. The general
be prescribed. These are usually reserved for use in treatment- symptoms of antidepressant discontinuation syndrome can
resistant patients under the supervision of a psychiatrist due to be summarised by the mnemonic FINISH: “Flu-like symptoms
their side effect and drug interaction profiles. (lethargy, fatigue, headache, achiness, sweating), Insomnia (with
vivid dreams or nightmares), Nausea (sometimes vomiting),
Physical therapies – Electroconvulsive therapy or transcranial
Imbalance (dizziness, vertigo, light-headedness), Sensory
magnetic stimulation can be tried.
disturbances (burning, tingling, electric-like or shock-like
sensations) and Hyperarousal (anxiety, irritability, agitation,
Intranasal esketamine aggression, mania, jerkiness)”.82 A more specific list of withdrawal
Intranasal esketamine (Spravato) is a newer treatment option effects for each class of antidepressant can be found in the
for treatment-resistant depression.80 It was approved for use Australian Medicines Handbook.
in Australia by the Therapeutic Goods Administration in March In addition to withdrawal symptoms, stopping antidepressants
2021 but is not currently listed on the Pharmaceutical Benefits can also result in relapse or exacerbation of the psychiatric illness.
Scheme (PBS). Intranasal esketamine is approved as an adjunct Such exacerbations can cause life-threatening behaviours in
to oral antidepressant therapy for treatment-resistant depression high-risk patients, and the decision to withdraw antidepressants
in adults and must be introduced in conjunction with a newly must be carefully considered and involve the patient, their next
initiated oral antidepressant. of kin (where appropriate) and the prescriber.
Esketamine is the S-enantiomer of racemic ketamine, a TGA- To reduce the risk of withdrawal symptoms and relapse, most
approved S8 anaesthetic and sedative that has previously been antidepressants should be tapered over several weeks at the
prescribed off-label and used intravenously for depression. end of a treatment course.73,78 The specific duration of the taper
The exact mechanism of action of esketamine in not known. depends on the elimination half-life of the medicine as well as
It is a N-methyl-D-aspartate (NMDA) receptor antagonist and the clinical urgency. It is important to educate patients about
evidence within the literature suggests that through NMDA the potential for withdrawal symptoms as well as the nature
receptor antagonism, esketamine produces a transient increase of these symptoms, and provide reassurance when they occur.
in glutamate release that improves synaptic functioning.81 Other strategies to assist with tapering when patients are finding
In Australia, it is currently only available through specialised it challenging include first switching the patient to fluoxetine
clinics overseen by psychiatrists as part of an early access (which rarely causes withdrawal symptoms due to its long
program. These clinics supply the medicine to the patients, who half-life as well as that of its active metabolite) and the use of
self-administer it at the clinic under the direct supervision of a benzodiazepines short term.78
healthcare professional who also monitors them for a period of Reasons for patients self-discontinuing antidepressants include
time after administration. experiencing marked adverse effects, a poor treatment response
or a poor relationship with their healthcare team.83,84 Pharmacists
have an important role in supporting patients to continue to
take their medicines and/or to work with healthcare teams to
plan antidepressant discontinuation. Understanding the reasons
why patients may wish to stop antidepressants, and encouraging
this as a planned event, can help reduce potential harm and
maintain therapeutic engagement between the patient and their
healthcare team. Pharmacists can provide patients with valuable
support in relation to their choices to continue, or discontinue,
treatment.85

Key points
• After commencing an antidepressant, patients should be reviewed every one or two weeks during acute treatment depending
on the individual treatment and their need.
• Lack of benefit with treatment at two to four weeks is an indicator that response to this particular treatment is unlikely.
• After recovery from a first episode of depression, six to twelve months continuing treatment is recommended. Continuation
beyond this time depends on the number of previous episodes, severity of the episode and adequacy of the remission.
• Risk factors for relapse of depression include presence of residual symptoms, number of previous episodes, severity and
duration of the most recent episode, degree of treatment resistance and, in older people, a greater degree of medical
comorbidity.
• Treatment-resistant depression is managed by a psychiatrist; treatment options include dose increase, antidepressant
augmentation and physical therapies (electroconvulsive therapy or transcranial magnetic stimulation).
• Abruptly stopping most antidepressants can result in withdrawal symptoms. To reduce the risk of withdrawal symptoms, these
antidepressants should be slowly tapered at the end of a treatment course.

23. You are asked for advice by a general practitioner 25. It is important to identify and address any factors that
(GP) about a patient who has been taking sertraline increase the risk of recurrent episodes during remission
50 mg mane for 4 weeks for a first episode of major of major depression. Which ONE of the following
depression; their appetite, sleep and concentration factors does NOT predict increased risk of recurrent
have improved, but their mood hasn’t. Which ONE of episodes of major depression?
the following advice is MOST appropriate at this time?
a) Presence of residual depressive symptoms.
a) Consider switching to duloxetine, taper sertraline,
b) Comorbidities; personality disorder, anxiety, medical
then start duloxetine at low dose.
conditions.
b) Consider adding lithium.
c) Number of previous episodes of depression.
c) Continue sertraline for another 4 weeks; increase the
d) Male gender.
dose to 75 mg mane if tolerated.
d) Consider switching to escitalopram, taper sertraline, 26. Treatment-resistant major depression is defined
then start escitalopram at low dose. as depressive symptoms that persist despite using
an effective dose of at least two antidepressants as
24. Which ONE of the following statements is MOST correct sequential monotherapy, each for a minimum of four
regarding response to an antidepressant? weeks. Which ONE of the following is NOT a strategy for
treatment-resistant depression?
a) Response to an antidepressant is predicted by an
initial benefit within the first week. a) Antidepressant augmentation with lithium,
triiodothyronine or an antipsychotic (e.g.
b) There is variable interindividual response to
quetiapine).
antidepressants and no way to predict which
antidepressant will be effective in a particular b) Bupropion.
patient. c) Irreversible nonselective monoamine oxidase
c) If a person does not respond to a selective serotonin inhibitors (e.g. tranylcypromine).
reuptake inhibitor (SSRI) after 4 weeks, it is likely they d) Electroconvulsive therapy (ECT).
will respond to a tricyclic antidepressant (TCA).
d) If a person has a small improvement but not full
resolution of symptoms from initial treatment, a
dose increase is unlikely to be helpful.

Section 6. Putting knowledge into practice
Learning objective Introduction

A pharmacist is an important member of the multidisciplinary
• Describe methods that can be utilised by pharmacists to
care team for patients with depression. They have a role to play
identify patients with depressive symptoms.
in a number of stages in a patient’s care pathway, including case-
• Identify key information to be included in patient
finding and screening, disease state and medication education,
psychoeducation.
identification and management of drug-related problems and
• Describe the role of the pharmacist in the management of monitoring of treatment adherence and effectiveness.77 Some
depression. of the key actions and interventions that pharmacists should
• Describe strategies to monitor patients being treated for consider at each stage are outlined below.
depression.
Screening and case-finding

While routine screening for depression is generally not
recommended, pharmacists are able to be involved in case-
finding through the identification of red flags when speaking
with patients about their health and any symptoms or concerns
they have. Red flags for depression include insomnia, fatigue,
chronic pain, recent life changes, poor self-rated health and
unexplained physical symptoms. If a pharmacist is concerned

that a patient may have depression, or identifies any red flags, it ideas unless specifically asked, and even then, may be somewhat
can be useful to ask the following two questions: guarded.5 The accessibility of pharmacies and pharmacists
• During the last month, have you often been bothered by means they are well positioned to identify people who self-harm,
provide mental health first aid (MHFA) and refer as required.
feeling down, depressed or hopeless?
• During the last month, have you often been bothered by There are many resources available to pharmacists to support
having little interest or pleasure in doing things? patients who are at risk of self-harm including:
If the patient answers yes to either of these questions they • Beyond Blue: Self-harm and self-injury available
should be referred to their GP for further assessment. at www.beyondblue.org.au/docs/default-source/
resources/268798_0914_bl1302_acc_3-18.
Mental health first aid pdf?sfvrsn=26cd51eb_0
• Orygen: MythBuster Self-harm: Sorting fact from fiction
Undertaking a Mental Health First Aid (MHFA) program can help available at www.orygen.org.au/Training/Resources/Self-
pharmacists to refine skills in identifying whether a person is harm-and-suicide-prevention/Mythbusters/Self-Harm/
developing depression. The general MHFA program has been Orygen_Self_Harm_Mythbuster?ext=.
specially adapted for pharmacists and pharmacy assistants to
enable development of the skills to help someone who they are
concerned about who appears to be developing a mental health
Management of depression
problem or experiencing a mental health crisis. Information With respect to the management of depression, the role of the
on MHFA courses can be found on the Mental Health First pharmacist includes:
Aid Australia website at mhfa.com.au/courses/public/types/ • Providing psychoeducation to the patient and their family,
blendedpharmacy.
carers and significant others about the diagnosis, including:
Akin to the common mnemonic used for an action plan in causes, symptoms, treatment options, course of the illness and
general first aid, DRSABCD, which stands for Danger, Response, possible outcomes, alleviating and aggravating factors and
Send for help, Airway, Breathing, Compressions and Defibrillator, how and where to seek treatment, when to contact a doctor
the MHFA program provides an action plan to help a person (e.g. increased suicidal thoughts), supports available, clearing
developing a mental health problem or experiencing a mental myths about the illness (e.g. it is not a sign of weakness), early
health crisis. The MHFA action plan mnemonic is ALGEE (Box 7). signs of relapse to look out for and lifestyle tips to improve
Box 7. Mental health first aid action plan outcomes.
• Counselling on any prescribed medicines, including the role of
the specific medicine, how to take the medicine, the expected
time to effectiveness, possible side effects (including the
risk of serotonin toxicity), the importance of adherence, the
importance of not stopping the medication suddenly (due to
the risk of withdrawal syndrome), food and drug interactions
to look out for (e.g. eating high tyramine foods when taking a
MAOI).77
• Providing advice on lifestyle factors and support to help
people with depression make changes to their lifestyle that
will be beneficial to their condition including:
– Sleep
· Explore the patient’s sleeping habits and provide sleep
Reference: Kitchener 86 hygiene advice if required. This can include: keeping
the room dark, quiet and comfortable; avoiding alcohol,
Although the action of assisting with a crisis is the highest caffeine and nicotine in the 4–6 hours before bed;
priority, the other actions of the MHFA action plan may need to maintaining a regular sleep–wake cycle; exercising
occur first (i.e. the steps don’t necessarily need to occur in a fixed regularly; and avoiding daytime naps.66
order). They appear in the order above simply to help remember
· Refer patients to sleep hygiene resources such as the
them. The first aider has to use good judgement about the order
Sleep Foundation website (www.sleepfoundation.org/
and relevance of these actions and needs to be responsive to the
sleep-hygiene) or Managing Insomnia Course (thiswayup.
person they are helping. Listening and communicating non-
org.au/courses/managing-insomnia-course/).
judgementally is an action that occurs throughout the giving of
first aid. · Recommend short term pharmacotherapy where
appropriate.
In addition to helping pharmacists refine their skills in identifying
– Diet
patients with depression, MHFA training can also provide
pharmacists with skills to identify patients who self-harm and · Provide advice and support to encourage healthy eating.
provide assistance. Patients may be reluctant to raise issues of · Provide information on the evidence for the benefits of a
self-harm and suicide.87 Most patients will not volunteer these Mediterranean diet.

– Exercise • Establishing a therapeutic relationship; this is the foundation
· Provide advice on the positive effects of regular exercise for the role of the pharmacist in supporting and managing
on depression. patients diagnosed with depression.5
· Support patients by providing resources and strategies to • Participate in the interdisciplinary management of patients
implement regular exercise in their life. with depression through Medschecks, Home Medicine
Reviews and case conferences. Emerging roles such as
· Refer patients to resources and support services such as
pharmacists in general practices, aged care homes, care homes
VicHealth’s database of health-related apps, including
serviced by disability providers and Aboriginal and Torres Strait
ones to encourage regular exercise (www.vichealth.vic.
Islander health services provide opportunities for pharmacists
gov.au/media-and-resources/vichealth-apps/healthy-
to become integrally involved in the interdisciplinary care of a
living-apps). person with depression.
– Smoking • Encourage involvement of the patient’s family where possible.
· Provide advice on the benefits of reducing smoking, Their involvement and support can provide a sense of
alcohol and other recreational substances, which include connection and belonging for the patient, aid recovery and
improving mood and an individual’s sense of autonomy lessen the risks associated with suicidal behaviour. Because
and control. living with a person with depression can affect family
· Support patients to reduce or quit smoking (e.g. members and close friends, pharmacists should consider the
through the provision of nicotine replacement therapy, impact on them and refer as needed.
information on prescription medicines that can assist • Support family members and/or carers of people with mental
and high-quality resources such as Quitline and the Quit health illness, including referral to support services. Support
website at www.quit.org.au/). Guidelines for pharmacists is available through Mental Health Carers Australia at
providing smoking cessation support are available at www.mentalhealthcarersaustralia.org.au/ which is a national
my.psa.org.au/s/article/Guidelines-for-pharmacists- advocacy group solely concerned with the well-being and
providing-smoking-cessation-support. Further promotion of the needs of families and carers supporting
someone with mental ill health. Other useful organisations
information on helping people with a mental health
include Tandem (at tandemcarers.org.au/) and Carers Australia
diagnosis to quit smoking can be found at www.health.
(at www.carersaustralia.com.au/).
gov.au/sites/default/files/supporting-someone-with-a-
mental-illness-to-quit-smoking.pdf.
– Alcohol and other recreational substances Monitoring of patients with
· Support patients to reduce or quit alcohol and other depression
recreational drugs through psychoeducation. Good • Checking in regularly with patients (especially when collecting
quality psychoeducation can be found online at www.
prescriptions) to assess effectiveness, adherence and any drug
headtohealth.gov.au/mental-health-difficulties/mental- related problems.
health-conditions/drugs-alcohol-and-other-substance- • Reminding patients to follow-up regularly with their treating
related-or-addictive-disorders. Useful tips and an app
doctor.
to assist people to modify alcohol use can be found at
• Ensuring anyone at risk of suicide who is started on a medicine
hellosundaymorning.org/.
that is associated with an increased risk of suicide has an
· Refer patients to appropriate support services such as the action plan to follow should suicidal thoughts occur.
Alcohol and Drug Foundation info and advice line and • Scheduling a Medscheck or facilitating a Home Medicine
website at adf.org.au/). Review (HMR), particularly if a patient in on > 5 medicines.
• Encouraging the patient to implement self-management • Identifying strategies to assist patients with adherence to
strategies to increase daily routine, including setting a regular medicines including:
wake and sleep time, seeking exposure to morning bright
– Providing education to patients, their families and carers on
light, avoiding naps during the day and ensuring stability of
the importance of adherence.
key social events (e.g. daily activities and meals).5
– Supporting patients with adherence to medicines
• Providing a brief intervention in lifestyle modification and
through dose administration aids, home delivery of
psychoeducation during clinical contact, such as when refilling
prescriptions or carrying out a MedsCheck or Home Medicine medicines, information on resources available (e.g. the
Review (HMR). NPS MedicineWise free app to help patients keep track of
• Optimising pharmacological management through: medicines and access important health information anytime
and anywhere, especially in emergencies at www.nps.org.
– assessing the safety of prescribed medicines (including
au/medicinewiseapp).
dose, drug interactions, comorbidities and overdose risk)
• Monitoring duration of treatment and, if relevant (i.e. the
and following up any identified drug related problems
patient appears to have had a full resolution of symptoms
– making recommendations on the most appropriate
and adequate treatment length), highlighting to the
medicine for a patient. prescriber that the patient may benefit from a review of their
antidepressant medicine.

Recommended resources for • In this together: Families and carers can ask. Supporting trans
and gender diverse young people in youth mental health.
patients and pharmacists www.orygen.org.au/Training/Resources/trans-and-gender-
diverse-young-people/Fact-sheets/in-this-together-families-
Resources for patients and-carers-can-ask
Other mental health organisations that pharmacists can direct • Gender diversity and language. www.orygen.org.au/Training/
patients with depression to include: Resources/trans-and-gender-diverse-young-people/Fact-
• Beyond Blue at: www.beyondblue.org.au sheets/Gender-diversity-and-language
• Lifeline at: www.lifeline.org.au or 13 11 14 • Intersectionality and youth mental health. www.orygen.org.
au/Training/Resources/trans-and-gender-diverse-young-
• Reach Out at: au.reachout.com
people/Fact-sheets/Intersectionality-and-youth-mental-
• Black Dog Institute at: www.blackdoginstitute.org.au
health/orygen_fact_sheet_intersectionality_and_ymh-pdf.
• Sane at: www.sane.org/ aspx?ext=
• Orygen at: www.orygen.org.au/
• MindSpot at: mindspot.org.au Mental health and COVID-19
• Moodgym at: moodgym.com.au The Oxford Precision Psychiatry 88 has developed a website
• To find a psychologist who is a member of the Australian (oxfordhealthbrc.nihr.ac.uk/our-work/oxppl/) that summarises the
Psychological Society, call 1800 333 497 or go to: best available clinical guidelines about key COVID-19 questions
www.psychology.org.au/Find-a-Psychologist that frontline mental health professionals are facing every day. The
• To find an accredited mental health social worker go to: website uses a rigorous methodological approach to search and
www.aasw.asn.au/find-a-social-worker/search/ select the information needed to answer these specific questions.
• To find an occupational therapist (mental health) go to: Pharmacists could access this website to research questions about
COVID-19 posed by patients with mental health issues.
www.otaus.com.au/find-an-ot
• COVID-19 Mental health resources are available for
consumers, health professionals and organisations at Initiatives pharmacists can be
www.phoenixaustralia.org/resources/coronavirus-covid-19 involved in to help raise awareness
Perinatal period of depression
• Perinatal Anxiety and Depression Australia (PANDA) website
(www.panda.org.au/) and helpline (1300 726 306) Movember
• Gidget Foundation Australian (free telehealth counselling for Movember is a global movement that raises awareness and funds
parents in perinatal period) at www.gidgetfoundation.org.au/ to improve Men’s Health. Specifically, Movember aims to make
a difference in mental health and suicide prevention, prostate
Veterans cancer and testicular cancer. During the month of November
• Department of Veterans Affairs (evidence-based mental health there is a fundraising campaign that focuses on people growing
treatments provided by mental health care professionals for a moustache or increasing activity.
mental health conditions are funded without the need for the
Pharmacists can get involved in a way that suits them and
condition to be accepted as related to service) www.dva.gov.
can involve staff so it is a team effort. This could be growing
au/health-and-treatment/injury-or-health-treatments/mental-
a moustache, or a staff team could commit to moving 60 km
health-care/free-mental-health-care-veterans
in the month of November. More information is available at
• Open Arms – Veterans & Families Counselling at
au.movember.com/.
www.openarms.gov.au
• Open Arms – High Res SMART (Self-Management and R U OK? Day
Resilience Training) treatment tools at www.openarms.gov.au/
R U OK? is a movement that contributes to suicide prevention
get-support/self-help-tools
efforts by encouraging people to invest more time in their
LGBTQIA+ personal relationships and building the capacity of informal
support networks – friends, family and colleagues – to be alert
Pharmacists need to understand how pronouns are used among
to those around them, have a conversation if they identify signs
LGBTQIA+ people and why they are important. It is often not
of distress or difficulty and connect someone to appropriate
possible to know a person’s pronouns just by looking at them.
support long before they are in crisis. R U OK? has developed
Asking and correctly using someone’s pronouns is one of the
free resources to encourage everyone in a school, workplace and
most basic ways to show your respect for gender identity.
community to think about who in their world might need to be
To learn more about pronouns, pharmacists can view: asked how they are really going and how to make a moment
• ‘What are pronouns and why are they important?’ at: www. meaningful by asking, “Are you OK?” Pharmacists may choose
minus18.org.au/articles/what-are-pronouns-and-why-are- to host an event such as a morning tea, webinar, sausage sizzle
they-important or a team picnic and can encourage others to be part of the
Orygen have a suite of resources that are focused on mental awareness raising and fundraising efforts. More information is
health of young LGBTQIA+ people including: available at www.ruok.org.au/.

Key points
• Pharmacists need to be able to provide quality information to people starting antidepressants about:
– the possible causes of depression
– what to expect when taking an antidepressant and how it might help
– how long before the antidepressant might start to have an effect and the approximate length of time it will need to be taken for
– possible adverse effects, and to have all reports of adverse events experienced taken seriously.
• Pharmacists can provide information and strategies to people prescribed antidepressants to reduce adverse effects associated
with antidepressants and optimise adherence.
• Pharmacists should encourage involvement of the patient’s family where possible; their support can aid recovery and lessen
the risks associated with suicidal behaviour.
• Pharmacists should highlight the important role of psychological strategies in the management and recovery from depression.
Patients practising techniques learned in cognitive behaviour therapy (CBT) or closely aligned therapeutic approaches to the
point where they become habit or automatic is a key step forward in recovery.
• There is a myriad of high-quality resources to support people with depression that are of a general nature or targeted towards
specific groups likely to be impacted by depression. Pharmacists should encourage patients with depression to access these
resources.

27. An effective screening approach that can be used by 29. Which ONE of the following is CORRECT regarding the
pharmacists is the ‘two-question’ tool. Which ONE role of pharmacists in the management of depression?
of the following options correctly identifies the two
questions? a) Provision of cognitive behavioural therapy (CBT) as
part of patient counselling.
a) “During the last month, have you experienced dark
b) Provision of nicotine replacement therapy to help
thoughts?”, “During the last month, have you lost or
the patient to reduce or quit smoking.
gained more than 5 kilograms?”
c) Referring patients who are not responding to
b) “During the last month, have you often been
antidepressant therapy to a psychiatrist for
bothered by feeling down, depressed or hopeless?”,
electroconvulsive therapy (ECT).
“During the last month, have you often been
bothered by having little interest or pleasure in d) Administration of intranasal esketamine to patients
doing things?” who have been prescribed the medicine by their
psychiatrist.
c) “During the last month, have you often been
agitated or aggressive?”, “During the last month,
30. Which ONE of the following is not a strategy to monitor
have you often seen or heard things that aren’t real?” a patient with depression?
d) “During the last month, have you often been
bothered by anxiety, felt stressed or had feelings a) Reviewing duration of antidepressant treatment
of worthlessness or excessive guilt?”, “During the when carrying out a Home Medicines Review (HMR).
last month, have your relationships with family and b) Checking patient adherence to their medication by
friends deteriorated?” reviewing the interval between prescription refills.
c) Asking the patient how they are going when
28. Regarding psychoeducation, which ONE of the
they are in the pharmacy to collect a refill of their
following statements is CORRECT?
medication.
a) Psychoeducation is only provided to the patient. d) Referring the patient to a local support service for
b) Psychoeducation focuses on drug interactions extra assistance.
associated with antidepressants.
c) Psychoeducation should only be provided to
the patient when they are first diagnosed with
depression.
d) Psychoeducation includes information on the clinical
course of the condition.

Section 7. Case scenario
Case scenario Over the past few months, you have noticed that Roger has not
been his usual self and appears to have lost weight. He is also
Mr Roger Drees is a 72-year-old retired looking somewhat dishevelled and unshaven, which is unusual.
About two years ago Roger shared with you that June’s memory
accountant who resides in the coastal town had been worsening and that she kept getting lost when she
where you work as a pharmacist. He attends was driving on her own. Soon after that, her GP organised for
the pharmacy regularly as he manages the her to see a geriatrician, and June has received a diagnosis of
Alzheimer’s disease.
medicines of his wife, June. He is always the
This morning, when you ask Roger about his week-end plans, he
first customer on a Saturday morning and
looks upset. You ask Roger if he would like to have a private chat
is often waiting in the car park before the and when he agrees, you take him to a private counselling area.
doors open; sometimes he brings produce Roger is tearful and tells you that he is ‘struggling’. He adds
or flowers to share with staff from his that June refuses to leave home, even for shopping and
garden. appointments, when she was previously very social. She
becomes very anxious whenever she is left at home alone and he
is feeling housebound and isolated.

You ask Roger some brief screening questions.
Counselling
• Tell me about your mood and how long you have been feeling
You talk through how best to manage sleep problems with sleep
like this?
hygiene techniques including:
• How well are you sleeping and how is your appetite?
• Do you still enjoy your favourite hobby/pastime? • not drinking caffeinated drinks within 6 hours of sleep
• making sure the bedroom is quiet and comfortable
Roger tells you he has been ‘struggling’ for several months. He
explains that June has been wakeful overnight and sleeping a (acknowledging June’s sleep disturbance is a factor)
lot in the day. June’s overnight wakefulness means his sleep is • taking moderate daily exercise
disturbed and he can’t go back to sleep until she does because • using relaxation techniques
he is worried she isn’t safe and he worries about what the future • if he is unable to get to sleep, to get out of bed and go to
holds. June has always been the family cook but she has lost another room to read, listen to soothing music and try to relax.
interest in cooking and when Roger tries to get her involved with You advise Roger that medicines are only part of the overall
mealtime preparations, she gets very frustrated and stressed. As treatment of depression and that talk therapy with a clinical
a result, they are mainly reheating pre-prepared frozen meals psychologist (or other trained mental health professional) is a
from the supermarket. He said he has ‘let the garden go’. Roger very effective intervention. You encourage him to resume playing
has also given up croquet, which was a great passion, and has croquet now that additional support for June will be available;
resigned as the croquet club treasurer because he was starting you are aware he is a popular and valued member of the croquet
to make some mistakes with the ledger. He said that he feels club and other club members would be very willing to support
tired all the time and feels like he has nothing to look forward him.
to. He has one son who moved to New Zealand five years ago
You acknowledge that when people are going through a tough
to be closer to his wife’s family. He hasn’t seen them since the
time, it can be tempting to use alcohol as a coping strategy. You
Christmas before the onset of the COVID-19 pandemic.
sensitively advise him that while alcohol is not contraindicated
You empathise with Roger about how challenging it is to be a with the more commonly used antidepressants, relying on
carer of someone with dementia – while caring for your loved alcohol can make existing mood problems worse and make
one can be rewarding, it can also have its tougher days. You recovery much harder.
encourage him to visit his GP to discuss these issues. You also
Roger accepts your offer to provide some written information, so
provide him with some resources from Dementia Australia (www.
you print off the following relevant resources:
dementia.org.au/education/family-carers-and-family-members).
• Causes of Depression www.blackdoginstitute.org.au/wp-
Roger returns a few days later to thank you for encouraging
content/uploads/2020/04/1-causesofdepression.pdf
him to go to the doctor. He had a long appointment with his
• Managing depression with exercise www.
GP who asked him to complete the Depression, Anxiety and
Stress Scale – 21 (DASS-21). His GP recommended ‘talk therapy’ blackdoginstitute.org.au/wp-content/uploads/2020/04/6-
and also advised that taking an antidepressant is an option. managingdepressionwithexercise.pdf
The GP provided him with a mental health plan to see a clinical • Quick relaxation techniques www.blackdoginstitute.org.au/
psychologist. Roger has rung around the clinical psychologists wp-content/uploads/2020/04/relaxationtechniques.pdf
in the coastal town, and all have closed their books but he has • Antidepressant medication www.beyondblue.org.au/docs/
an appointment with a clinical psychologist via telehealth in default-source/resources/bl0125-antidepressant-medication-
the city in four months’ time. The practice nurse has given him fact-sheet-acc.pdf?sfvrsn=fc1646eb_2
some information about help he can get through the local Roger thanks you for the information and decides that after
council and is organising for June to attend ‘day care’ at one of reading through the resources, he will have a discussion with his
the local aged care homes. Roger admits to having ‘the blues’ son and his wife in New Zealand about next steps.
when his first marriage broke down 25 years ago but ‘he got
through it somehow’ and then met June, ‘the love of his life’. He
has always prided himself on his good health and the fact that
Two months later
he only needs to take paracetamol for an occasional headache. Over the past two months, Roger has continued to attend the
He asks for more information on managing his (and June’s) sleep pharmacy and you have enquired about how he has been feeling
disturbance and other non-pharmacological options. He also from time to time when he collects June’s medicines. June has
would like more information about antidepressants (to help him been in respite for the past 3 weeks. He said that he has been
consider whether he would like to try this option mentioned by trying to exercise and drink less alcohol, but he is ‘fighting a
his doctor), especially side effects. He is also interested to know if losing battle’. He said that he has been feeling frustrated and
he is able to combine an antidepressant with alcohol as it is ‘the angry and is not very good company, so he hasn’t resumed
only pleasure in my life at the moment’. croquet. You encourage him to have a further discussion with his
GP as it is still two months before his psychology appointment.
The following week, Roger returns with a prescription for
sertraline. After you have dispensed the sertraline, you invite
Roger to the counselling room. After a diagnosis of depression
an individual often requires a period of adjustment as they

processes the diagnosis. Some people feel that a diagnosis of
depression means they have failed, which is reinforced by the
Four months later
stigma associated with ‘tough men’ who don’t discuss their Four months later, Roger arrives at the pharmacy with a basket
feelings. of citrus fruit for the pharmacy staff to share. You have been
observing a gradual improvement in Roger over the past months
You reinforce the information about what to expect with
and today you are thrilled to see Roger seems much more like
commencing sertraline and check with him that he is
his usual self. He tells you that June spent six weeks in respite,
appropriately supported by friends, family and his healthcare
which was a welcome ‘circuit breaker’, and since returning home
team. You offer to check in with him after a week to see how he is
there are many more supports in place. He has resumed playing
managing. You highlight that it is necessary to take the sertraline
croquet twice a week while a carer is with June, and they have
continuously as stopping an antidepressant abruptly can result in
healthy ‘home-made’ meals delivered on weekdays. Roger
a withdrawal syndrome that can include disrupted sleep, feeling
now only consumes alcohol after a game of croquet or when a
agitated and experiencing electric shock-like experiences.
mate drops in and limits it to two light beers. June’s sleep has
You advise him to discuss with you or his GP if he is thinking improved, and her friends have rallied and visit regularly, which
about stopping sertraline so that a managed withdrawal of is impacting positively on her mood. Roger has commenced
treatment can be planned, an alternative can be considered telehealth sessions with a psychologist in the city and they are
and ensure the change to another antidepressant occurs safely. working on strategies to manage triggers and ongoing stress.
You advise him that around 30% of people respond to the first Roger and June now have a regular Zoom meeting every Sunday
antidepressant trialled and it may take some time to find an night with his son and family in New Zealand, which both Roger
antidepressant that suits. You reinforce the additional benefits and June look forward to.
that the ‘talk therapy’ will provide when the appointment
eventuates and the importance of other protective and lifestyle
factors that can improve outcomes. As you recently started
packing June’s medicines, you ask Roger if he thinks a blister pack
will be helpful to promote adherence.

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Approach to treating adults with major depression 18 Key points: 38

Approach to treating children and adolescents with Multiple choice questions 38

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How to earn CPD credits

Standard 2.2: Collaborate with professional colleagues

Standard 2.3: Communicate effectively

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Learning objectives Definition of depression

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Role of circadian function

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Essential CPE – Depression I © Pharmaceutical Society of Australia Ltd. 9

10 Essential CPE – Depression I © Pharmaceutical Society of Australia Ltd.

The impact of depression Key points

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Learning objectives Risk factors

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Approach to treating adults with

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Multiple choice questions

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Although depression is a chronic, often lifelong, illness, resilience

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Non-pharmacological management • Red meats in small amounts. Reduce saturated fats.

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Mechanism of Adverse effect Hepatic Overdose

Essential CPE – Depression I © Pharmaceutical Society of Australia Ltd.

vortioxetine c SRI + 5-HT3 + − − − − ++ +/- − − ?

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Multiple choice questions

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Learning objectives Follow-up and monitoring

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Multiple choice questions

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Learning objective Introduction

Screening and case-finding

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Multiple choice questions

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