PS5.1-2 | Depression in Primary Care — Summary & Reflection

KEY TAKEAWAYS

Major depressive disorder is defined by ≥2 weeks of depressed mood and/or anhedonia plus associated neurovegetative, cognitive, and somatic symptoms (DSM-5: ≥5 symptoms; ICD-11 similar). It presents frequently in primary care, often with somatic masking.

The biopsychosocial model integrates biological (genetic, neurochemical, medical), psychological (cognitive schemas, previous episodes), and social (life events, social support) determinants.

The mental status examination in depression reveals low/dysphoric mood, constricted blunted affect, psychomotor retardation, poverty of speech, themes of worthlessness/guilt, and potentially suicidal ideation. Suicidal ideation assessment is mandatory.

Management: SSRIs are first-line (escitalopram, sertraline, fluoxetine, paroxetine); TCAs and MAOIs are not first-line in primary care. Clinical response begins at 2–4 weeks; full effect at 6–8 weeks; continue 6–9 months post-remission for a first episode.

Red-flag referral triggers: active suicidality with plan/means, psychotic features, severe functional impairment, suspected bipolarity (risk of SSRI-induced mania), treatment resistance (two failed adequate trials).

Serotonin syndrome vs NMS: hyperreflexia + clonus + fast onset (SS) vs lead-pipe rigidity + bradyreflexia + slow onset (NMS).

Mental Healthcare Act 2017 decriminalises suicide attempt and replaces the 1987 Act.

REFLECT

Think about a patient in your community — perhaps a family member, neighbour, or someone you have observed in a waiting room — who may have been living with unrecognised depression for months or years. What barriers might have prevented them from seeking help? Consider stigma, the tendency to attribute low mood to personal weakness ('just tension'), and the cultural normalisation of somatic symptoms over emotional distress. As a clinician, what specific change in the way you take a history could increase the likelihood of detecting depression during a routine primary-care consultation? How might your approach differ when the presenting complaint is physical but the underlying issue is emotional?