Diagnosis

1. Diagnostic procedures begin with an adequate alertness for depression.

Suspicion of depression is confirmed by affirmative answers to at least one of the following questions:

·    “During the last 2 weeks, have you been frequently been troubled by depressive thoughts or feelings of helplessness?” and/or

·    “Have you been troubled by a lack of interest or pleasure in things you have done during the last two weeks?”

Level 2

2. Causes other than depression need to be excluded  by checking presence of: 

·    Serious or critical, yet treatable psychiatric diseases (e.g. bipolar disorder),

·    Other treatable underlying problems which may occur with depression (e.g. hypothyroidism),

·    Treatable problems which may be accompanied by depressive symptoms or depression but which need a specific therapeutic approach (e.g. stress).

Level 3

3. To gain a complete picture of depression, one should look at:

·    The evaluation according to DSM-IV criteria,

·    The impact on psychosocial functioning,

·    Resiliance,

·    Causal or protective factors.

Level 3

Treatment

4. The GP always needs to check if the patient has suicidal thoughts and the suicide risk must be discussed.

In case of serious risks, immediate referral to specialised support is proposed.

Level 3

5. In case of mild and moderate depression, the patient should be treated with non-pharmacological intervention.
In case of severe depression, specialized psychotherapeutic treatment should be combined with antidepressants.

Level 1

6. As a minimum, the non-pharmacological approach of the general practitioner consists of:

·    clarifying complaints, and protective factors,

·    psychoeducation,

·    activation of the patient.

Level 2

7. Antidepressant medication is recommended only for severe depression in primary care, in particular TCAs or SSRIs.

Level 1

8. The choice between TCAs and SSRIs is based on:

·    the risk of side effects,

·    drug interactions,

·    risk of suicide,

·    cost.

Level 2

9. If the choice is given to:

·    TCAs: amitriptyline, imipramine or nortriptyline are preferred,

·    SSRIs: fluvoxamine, paroxetine, sertraline, citalopram or fluoxetine are preferred,

·    For the elderly, sertraline or citalopram are preferred.

Level 2

10. Non-pharmacological follow-up is always pursued.

In case of severe depression, antidepressants are added.

Level 1

11. Relapse can be prevented in patients at risk by:

·    Treating them with medication over longer periods and by reducing medication more slowly,

·    Proposing continuous psychotherapeutic counselling (preferably behavioural therapy).

Level 2

11. Referral to a psychiatrist is made in the following cases:

·    The general practitioner does not perform psychotherapeutic counselling,

·    There is no adequate result after > 4-6 weeks,

·    Severe depression with poor prognosis or major suicidal tendencies.

Level 2

13. Use existing local or regional initiatives for collaborative care in cases where prolonged treatment is needed. For this reason, social services mapping is desirable.

Level 3