Med2Date — Clinical Guidelines
Home Family Medicine Depression

Depression

Last updated 31 May 2026 · Psychiatry / General Practice

📋 Key Information Summary

📋
  • Major depressive disorder (MDD) affects approximately 1 in 7 Australians during their lifetime, with a 12-month prevalence of around 4.1% (ABS National Study of Mental Health and Wellbeing 2020–22).
  • Diagnosis requires ≥5 of 9 DSM-5 criteria (including at least one of depressed mood or anhedonia) present for ≥2 weeks, causing clinically significant distress or functional impairment.
  • The PHQ-9 (Patient Health Questionnaire-9) is the recommended screening and severity tool in Australian general practice; scores of 5–9 mild, 10–14 moderate, 15–19 moderately severe, 20–27 severe.
  • Every assessment must include direct questioning about suicidal ideation, intent, plan, and access to means — use the SAD PERSONS mnemonic as a structured risk stratification aid.
  • First-line pharmacotherapy for moderate-to-severe depression is an SSRI (sertraline or escitalopram preferred); SNRIs (venlafaxine, duloxetine) are second-line or for comorbid pain syndromes.
  • Psychotherapy (CBT, IPT) is first-line for mild-to-moderate depression and is recommended in combination with medication for moderate-to-severe disease; accessible via Better Access to Mental Health (MBS items 80000–80020).
  • Perinatal depression affects up to 1 in 5 Australian women; sertraline is the preferred SSRI in breastfeeding; screening with the Edinburgh Postnatal Depression Scale (EPDS) is recommended at 6–12 weeks postpartum.
  • Depression in older adults is frequently under-recognised; SSRIs remain first-line but caution is required with falls risk, hyponatraemia (especially with SSRIs), drug interactions, and bleeding risk.
  • Adolescents should receive psychotherapy (CBT or IPT-A) as first-line; fluoxetine is the only SSRI with TGA approval for MDD in those aged ≥8 years in Australia.
  • Aboriginal and Torres Strait Islander peoples experience depression at 2–3 times the rate of non-Indigenous Australians; culturally safe, trauma-informed, and community-based approaches are essential.
  • Treatment-resistant depression (failure of ≥2 adequate antidepressant trials) warrants specialist referral; augmentation strategies include lithium, aripiprazole, or quetiapine.
  • Patients started on antidepressants require close follow-up at 2 weeks, then 4 weeks, and ongoing review for at least 6–12 months after remission before considering tapering.

Introduction & Australian Epidemiology

Depression is one of the most common presentations in Australian general practice, accounting for an estimated 3.3 million GP encounters annually. Major depressive disorder (MDD) is characterised by persistent low mood and/or loss of interest or pleasure, accompanied by a constellation of cognitive, behavioural, and somatic symptoms that cause significant functional impairment.

In Australia, the 2020–22 National Study of Mental Health and Wellbeing (Australian Bureau of Statistics) found that approximately 8.6 million Australians (42.9% of those aged 16–85) had experienced a mental disorder at some point in their lifetime, with depressive disorders among the most prevalent. The 12-month prevalence of MDD is approximately 4.1%, with higher rates observed in females, younger adults, those in lower socioeconomic groups, and people living in remote or very remote areas.

Depression is a leading cause of disability-adjusted life years (DALYs) globally and is the leading cause of suicide-related mortality in Australia. In 2022, there were 3,249 deaths by suicide in Australia (AIHW), making suicide the 15th leading cause of death overall and the leading cause of death for Australians aged 15–44. Men account for approximately 75% of deaths by suicide, although women attempt suicide at higher rates.

⚠️
Key Australian data: Depression is the most commonly managed mental health condition in general practice (BEACH programme data; NFPPI). Only approximately 50% of people with depression in Australia receive treatment, highlighting a major treatment gap that is even wider in rural, remote, and Aboriginal and Torres Strait Islander communities.

The economic burden of depression in Australia is estimated at .6 billion annually in direct health costs and lost productivity (Productivity Commission Mental Health Inquiry Report, 2020). Depression commonly coexists with chronic medical conditions — including cardiovascular disease, diabetes mellitus, chronic pain, and cancer — and worsens outcomes for these conditions through reduced adherence, increased morbidity, and higher mortality.

Diagnostic Approach & Depression Scales

DSM-5 Diagnostic Criteria for Major Depressive Episode

Diagnosis of MDD requires the presence of ≥5 of the following 9 symptoms during the same 2-week period, representing a change from previous functioning. At least one symptom must be (1) depressed mood or (2) loss of interest or pleasure (anhedonia):

  1. Depressed mood most of the day, nearly every day
  2. Markedly diminished interest or pleasure in all or almost all activities
  3. Significant weight change (≥5% in 30 days) or appetite change
  4. Insomnia or hypersomnia nearly every day
  5. Psychomotor agitation or retardation (observable by others)
  6. Fatigue or loss of energy nearly every day
  7. Feelings of worthlessness or excessive/inappropriate guilt
  8. Diminished ability to think, concentrate, or make decisions
  9. Recurrent thoughts of death, suicidal ideation, or suicide attempt/plan
🚨
Exclusion criteria — always consider: Symptoms must not be attributable to a substance (medication, drug of abuse) or another medical condition (e.g. hypothyroidism, vitamin B12 deficiency, iron deficiency anaemia, obstructive sleep apnoea, malignancy). Perform targeted investigations to exclude medical mimics before confirming a diagnosis of primary MDD.

Recommended Screening and Severity Tools

Instrument Items Scoring Best Use in Australian Practice
PHQ-9 (Patient Health Questionnaire-9) 9 0–4 minimal, 5–9 mild, 10–14 moderate, 15–19 mod-severe, 20–27 severe Primary screening, severity assessment, and treatment monitoring; endorsed by RACGP
PHQ-2 2 ≥3 = positive screen → proceed to PHQ-9 Brief initial screen in time-limited consultations
DASS-21 (Depression Anxiety Stress Scales) 21 (7 per subscale) Normal, mild, moderate, severe, extremely severe (each subscale) Concurrently screens anxiety and stress; commonly used in Australian psychology
K-10 (Kessler Psychological Distress Scale) 10 10–19 low, 20–24 moderate, 25–29 high, 30–50 very high distress Used in ATSI health assessments (MBS Item 715) and Medicare-funded GP Mental Health Treatment Plans
EPDS (Edinburgh Postnatal Depression Scale) 10 ≥13 suggests depression; ≥10 warrants further assessment Perinatal screening — recommended at antenatal booking and 6–12 weeks postpartum
HEADS-ED (adolescent) 7 0–24; higher score = higher acuity Emergency department and acute adolescent assessment

Essential Medical Exclusions (Investigations to Consider)

Essential TSH, free T4 Exclude hypothyroidism / hyperthyroidism — commonly presents with mood symptoms
Essential FBC (full blood count) Exclude iron deficiency anaemia, chronic illness
Available Vitamin B12, folate Particularly in elderly, malnourished, or vegans — deficiency causes neuropsychiatric symptoms
Available Vitamin D (25-OH) Widely deficient in Australian population; association with depressive symptoms
Available LFTs, eGFR, electrolytes Baseline organ function prior to commencing antidepressant therapy
Available HbA1c / fasting glucose Screen for diabetes — bidirectional association with depression
Available MSU / urinalysis If urinary symptoms — UTI in elderly can present as depression/confusion
Specialist CT brain / MRI If cognitive decline, focal neurological signs, or atypical presentation — exclude space-occupying lesion or vascular dementia

Differential Diagnosis

  • Bipolar disorder — always screen for prior manic/hypychotic episodes before initiating antidepressants (use MDQ — Mood Disorder Questionnaire)
  • Persistent depressive disorder (dysthymia) — chronic low mood ≥2 years
  • Adjustment disorder with depressed mood — clear psychosocial stressor within 3 months
  • Grief/bereavement — normal grief ≠ MDD unless persistent >12 months with marked functional impairment (prolonged grief disorder)
  • Anxiety disorders — commonly comorbid; GAD, PTSD, social anxiety
  • Substance use disorder — alcohol, cannabis, methamphetamine
  • Medical: hypothyroidism, Cushing's syndrome, MS, Parkinson's disease, pancreatic cancer

Suicidal Ideation & Risk Assessment (SAD PERSONS)

🚨
Every patient with suspected depression must be asked directly about suicidal thoughts. "Have you had any thoughts that life is not worth living, or thoughts of harming yourself or ending your life?" Direct questioning does not increase risk — it opens a critical safety conversation.

Levels of Suicidal Ideation

Low Risk
Passive Ideation
"I wish I wasn't here" or "I wouldn't mind if I didn't wake up." No plan, no intent, no self-harm behaviours.
Setting: GP with safety plan, follow-up in 1–2 weeks
Moderate Risk
Active Ideation Without Plan
Thoughts of ending life but no specific method, timeline, or intent. Some protective factors may remain.
Setting: Urgent GP Mental Health Treatment Plan, crisis plan, weekly follow-up, consider referral to local mental health service
High Risk
Active Ideation With Plan and/or Intent
Specific method identified, access to means, timeline determined, and/or recent self-harm. Protective factors absent.
Setting: Do NOT leave alone — arrange immediate transfer to ED or crisis team (e.g. Lifeline 13 11 14, emergency services 000)

SAD PERSONS Mnemonic for Suicide Risk Assessment

Letter Risk Factor Assessment Points
S Sex Male sex — higher completed suicide rate (M:F = 3:1); higher lethality methods
A Age Adolescents/young adults (15–24) and elderly males (≥65) — highest risk cohorts
D Depression Severity of depressive episode — hopelessness is the strongest predictor of suicidal behaviour
P Previous attempt Prior self-harm or suicide attempt — single strongest predictor of future attempt
E Ethanol (alcohol) abuse Current alcohol or substance misuse — lowers inhibition, increases impulsivity
R Rational thinking loss Psychosis, severe cognitive impairment, delirium, command hallucinations
S Separated/divorced Social isolation, relationship breakdown, living alone, lack of social supports
O Organised plan Specific method, timeline, access to lethal means (firearms, stockpiled medications)
N No social supports Absence of family, friends, community, or cultural connection
S Sickness (chronic illness) Chronic pain, terminal diagnosis, recent major medical event, functional decline

Additional Risk and Protective Factors

🔴 Risk Factors
  • Access to lethal means (firearms, stockpiled medications, pesticides)
  • Recent psychiatric hospital discharge
  • Family history of suicide (first-degree relative)
  • Indigenous Australians — suicide rates 2× non-Indigenous
  • LGBTIQ+ individuals — particularly transgender youth
  • Occupational exposure: farmers, veterinarians, first responders, military
  • Imprisonment and recent release from custody
🟢 Protective Factors
  • Strong family/social connections and cultural identity
  • Children in the home (for parents)
  • Engagement with treatment and follow-up
  • Religious/spiritual beliefs against suicide
  • Problem-solving ability and future orientation
  • Willingness to seek help and disclose distress
  • Safe storage of medications and firearms removal
⚠️
Safety planning: For all patients identified with any level of suicidal ideation, develop a written Safety Plan collaboratively (Stanley & Brown model). This includes warning signs, coping strategies, social contacts for distraction, professional contacts (GP, Lifeline 13 11 14, Beyond Blue 1300 22 4636, Kids Helpline 1800 55 1800), and means restriction. Provide a printed copy to the patient and their nominated support person.

Key Australian Crisis Resources

Service Contact Availability
Lifeline 13 11 14 24/7
Beyond Blue 1300 22 4636 24/7
Kids Helpline (5–25 yrs) 1800 55 1800 24/7
Suicide Call Back Service 1300 659 467 24/7
13YARN (Aboriginal and Torres Strait Islander) 13 92 76 24/7
QLife (LGBTIQ+) 1800 184 527 3 pm – midnight daily
MensLine Australia 1300 78 99 78 24/7
Open Arms (veterans & families) 1800 011 046 24/7

Depression in Special Populations

🧒

Adolescents (12–17 years)

Epidemiology: Approximately 5% of Australian adolescents meet criteria for MDD; rates higher in Aboriginal youth and LGBTIQ+ youth. Onset of MDD is often insidious and may present as irritability, academic decline, social withdrawal, or somatic complaints.
Screening: HEADS-ED or PHQ-A (adapted PHQ-9). Screen at all adolescent health checks. Confidential consultations (mature minor principle) with parent/carer engagement.
First-line treatment: Psychotherapy — CBT or interpersonal therapy for adolescents (IPT-A). Accessible via GP Mental Health Treatment Plan (MBS Item 80110) → up to 20 sessions per calendar year.
Pharmacotherapy — fluoxetine (Prozac®) is the only SSRI with TGA approval for MDD in children ≥8 years in Australia. Start 10 mg daily, increase to 20 mg after 1–2 weeks. Maximum 60 mg daily.
Alternative: sertraline (Zoloft®) — used off-label but with evidence base. Start 25–50 mg daily, titrate to 100–200 mg daily.
⚠️
Black box warning: All antidepressants carry a TGA warning regarding increased risk of suicidal thinking and behaviour in children, adolescents, and young adults (under 25). Close monitoring required — weekly face-to-face or telehealth review for the first 4 weeks, then fortnightly. Combined treatment (therapy + medication) is superior to either alone in moderate-severe adolescent depression.
🤰

Perinatal Depression

Epidemiology: Affects 10–20% of Australian women during pregnancy and/or the first 12 months postpartum. Paternal perinatal depression affects ~10% of new fathers.
Screening: Edinburgh Postnatal Depression Scale (EPDS) — recommended at antenatal booking visit, third trimester, and 6–12 weeks postpartum (Pregnancy Care Guidelines, Australian Government). Score ≥13 warrants further clinical assessment.
Mild–moderate: Psychotherapy (CBT, IPT) is first-line. Perinatal-specific programs (e.g. MumMoodBooster, online CBT) available via digital mental health services.
Pharmacotherapy — sertraline (Zoloft®) 50–200 mg daily is the preferred SSRI in breastfeeding (low relative infant dose ~0.5–2%). Paroxetine also acceptable in breastfeeding but is Category D in pregnancy.
In pregnancy: sertraline and fluoxetine have the most safety data. Avoid paroxetine (Category D — cardiac malformations). All SSRIs: neonatal adaptation syndrome possible (irritability, jitteriness, respiratory symptoms) — usually self-limiting. Weigh risks of untreated depression against medication risks.
Brexanolone (Zulresso®) and zuranolone (Zurzuvae®) — novel neurosteroid agents for postpartum depression; not yet PBS-listed in Australia; specialist-initiated only.
💡
Key message: Untreated perinatal depression carries significant risks for mother (self-harm, impaired bonding), infant (developmental delay, behavioural problems), and family. The benefits of treatment generally outweigh risks. Refer to a perinatal mental health service or consultant psychiatrist for severe or complex cases.
👴

Older Adults (≥65 years)

Epidemiology: Depression affects 10–15% of older Australians in the community and up to 30% in residential aged care facilities (RACFs). Commonly under-recognised due to somatic presentation, stigma, and attribution to "normal ageing."
Screening tools: PHQ-9, GDS-15 (Geriatric Depression Scale — 15-item), or K-10. Use validated tools during 75+ health assessments (MBS Item 707) and annual RACF reviews.
Key differential considerations: Delirium, dementia (especially early Alzheimer's), bereavement, chronic pain, isolation, polypharmacy, substance use (alcohol), thyroid disease, vitamin B12/folate deficiency.
Pharmacotherapy — sertraline (Zoloft®) 25–100 mg daily (start low — 25 mg, titrate slowly) or escitalopram (Lexapro®) 5–10 mg daily. Both preferred for lower drug interaction profiles and cardiac safety. Avoid citalopram at doses >20 mg (QTc prolongation risk per TGA safety advisory).
Venlafaxine (Efexor-XR®) — useful if concurrent chronic pain; caution with hypertension and falls risk. Mirtazapine (Avanza®) 15–30 mg nocte — beneficial when insomnia and appetite loss are prominent; sedation may be advantageous but watch for increased falls risk.
⚠️
Key safety concerns in the elderly: SSRIs increase risk of hyponatraemia (SIADH) — check sodium at baseline, 2 weeks, and periodically thereafter. SSRIs increase GI bleeding risk (especially with concurrent NSAIDs or anticoagulants) — consider PPI cover. Fall risk increased with all antidepressants — medication review and falls prevention strategies essential. All antidepressants — start at half the usual adult dose and titrate slowly.
🫘

Renal Impairment

Sertraline — no dose adjustment required in mild–moderate CKD; use with caution in severe CKD (eGFR <15) — limited data.
Escitalopram — no dose adjustment for mild–moderate renal impairment; caution in severe CKD.
Venlafaxine — avoid active metabolite accumulation in eGFR <30; consider dose reduction or use alternative.
Mirtazapine — reduce dose in severe renal impairment (eGFR <15); start 15 mg every second day.
🫁

Hepatic Impairment

Sertraline — halve dose in severe hepatic impairment (Child-Pugh C); use with caution.
Escitalopram — halve dose in moderate hepatic impairment; avoid in severe hepatic impairment.
Venlafaxine — halve dose in moderate hepatic impairment; avoid in severe.
Fluoxetine — use with caution; long half-life and active metabolites accumulate.
🛡️

Comorbid Chronic Disease

Cardiovascular disease: Depression is an independent risk factor for worse cardiovascular outcomes. SSRIs (particularly sertraline) are safe post-MI and in heart failure (SADHART trial). Avoid TCAs — pro-arrhythmic. Screen all cardiac rehabilitation patients with PHQ-2/9.
Diabetes mellitus: Bidirectional association. Depression reduces glycaemic control and self-care. SSRIs may modestly improve HbA1c. Integrate mental health into diabetes cycle of care.
Chronic pain: SNRIs (duloxetine, milnacipran) or TCAs (amitriptyline 10–75 mg nocte) have dual benefit. Duloxetine (Cymbalta®) 60 mg daily is first-line for comorbid depression and neuropathic pain (PBS Authority Required).
Cancer: Depression prevalence 20–30%. Screen at diagnosis and during treatment. Psychotherapy preferred for mild-moderate; SSRIs for moderate-severe. Avoid fluoxetine with tamoxifen (CYP2D6 inhibitor — use sertraline or citalopram instead).

Management of Depression

Stepwise Approach to Management

1
Mild Depression (PHQ-9: 5–9)
Watchful waiting (2–4 weeks) with active follow-up. Psychoeducation, sleep hygiene, physical activity prescription (≥150 min/week moderate exercise — Black Dog Institute recommendation). Self-guided digital CBT (e.g. MindSpot Clinic, THIS WAY UP). If no improvement → step up to psychotherapy.
2
Mild-to-Moderate Depression (PHQ-9: 10–14)
Psychotherapy is first-line — CBT, IPT, or behaviour activation. GP Mental Health Treatment Plan (MBS Item 80110) → up to 20 individual sessions per calendar year (as of January 2023 permanent increase from 10 to 20). Consider pharmacotherapy if poor response to psychotherapy alone after 6–8 weeks.
3
Moderate-to-Severe Depression (PHQ-9: ≥15)
Combined treatment (pharmacotherapy + psychotherapy) is recommended for best outcomes. Commence antidepressant therapy. If severe or psychotic features → urgent referral to psychiatrist or crisis team; consider inpatient admission.
4
Treatment-Resistant Depression
Defined as failure to respond to ≥2 adequate antidepressant trials (adequate dose for ≥6 weeks). Options: switch antidepressant class, augmentation (lithium, atypical antipsychotic, thyroid hormone), combination antidepressants, ECT, rTMS, ketamine/esketamine (Spravato® — specialist only). Refer to psychiatrist.

Pharmacotherapy — First-Line Antidepressants

💊
Sertraline
Zoloft® · Generic · SSRI
Adult dose Start 50 mg PO mane; titrate by 25–50 mg every 1–2 weeks; target 100–200 mg daily
Paediatric dose ≥6 yrs (off-label): 25 mg daily, titrate to 50–200 mg daily
Renal adjustment No adjustment required in mild–moderate; caution in eGFR <15
Hepatic adjustment Halve dose in severe hepatic impairment
Key interactions MAOIs (contraindicated), tramadol (serotonin syndrome risk), warfarin (increased INR)
PBS status ✔ PBS General Benefit
💊
Escitalopram
Lexapro® · Generic · SSRI
Adult dose Start 10 mg PO mane; increase to 20 mg after 1–2 weeks if needed
Paediatric dose ≥12 yrs: 10 mg daily (TGA approved); max 20 mg daily
Renal adjustment No adjustment for mild–moderate; caution in severe CKD
Hepatic adjustment Halve dose in moderate impairment; avoid in severe
Key interactions MAOIs (contraindicated), QTc-prolonging agents at doses >20 mg
PBS status ✔ PBS General Benefit
💊
Fluoxetine
Prozac® · Generic · SSRI
Adult dose Start 20 mg PO mane; increase to 40–60 mg daily after 4–6 weeks if needed
Paediatric dose ≥8 yrs: 10 mg daily for 1 week, then 20 mg daily; max 60 mg daily
Renal adjustment No adjustment required
Hepatic adjustment Reduce dose or frequency; long half-life — slower washout
Key interactions Potent CYP2D6 inhibitor — interacts with tamoxifen, codeine, TCAs. MAOIs contraindicated.
PBS status ✔ PBS General Benefit

Second-Line Antidepressants

💊
Venlafaxine XR
Efexor-XR® · Generic · SNRI
Adult dose Start 75 mg PO mane (37.5 mg in elderly); titrate to 150–225 mg daily; max 375 mg (hospital only)
Renal adjustment Reduce dose by 50% if eGFR <30
Hepatic adjustment Halve dose in moderate; avoid in severe impairment
Key interactions MAOIs (contraindicated); increases blood pressure — monitor BP; discontinuation syndrome common — must taper
PBS status ✔ PBS General Benefit
💊
Duloxetine
Cymbalta® · Generic · SNRI
Adult dose Start 30 mg PO daily for 1 week, then 60 mg daily; max 120 mg daily
Renal adjustment Avoid if eGFR <30
Hepatic adjustment Contraindicated in severe hepatic impairment
Key interactions MAOIs (contraindicated); monitor BP; avoid with alcohol (hepatotoxicity risk)
PBS status ⚠️ PBS Authority Required — for MDD AND comorbid neuropathic pain
💊
Mirtazapine
Avanza® · Generic · NaSSA
Adult dose Start 15 mg PO nocte; titrate to 30–45 mg nocte
Renal adjustment Reduce dose in eGFR <15
Hepatic adjustment Use with caution; reduce dose
Key features Sedation, appetite stimulation, weight gain. Useful in elderly with insomnia, anorexia, or nausea. Less GI upset and sexual dysfunction than SSRIs.
PBS status ✔ PBS General Benefit

Augmentation Strategies (Specialist Initiated)

Agent Dose Monitoring PBS Status
Lithium (Priadel®) 250–1000 mg daily (target serum level 0.4–0.8 mmol/L) Lithium levels at 1 week, then every 6 months; renal function, thyroid, calcium ✔ PBS General Benefit
Aripiprazole (Abilify®) 2–5 mg daily as augmentation Weight, lipids, HbA1c, metabolic monitoring ⚠️ PBS Authority Required
Quetiapine (Seroquel®) 150–300 mg daily as augmentation Metabolic monitoring, ECG, sedation ⚠️ PBS Authority Required (augmentation use)

Non-Pharmacological Therapies

Psychotherapy
  • CBT (Cognitive Behavioural Therapy) — most evidence-based; 12–20 sessions; effective across severity
  • IPT (Interpersonal Therapy) — particularly effective for interpersonal conflict, grief, role transitions
  • Behaviour Activation — effective and can be delivered by trained allied health
  • ACT (Acceptance and Commitment Therapy) — growing evidence, especially for chronic/recurrent depression
  • MBCT (Mindfulness-Based Cognitive Therapy) — reduces relapse in recurrent depression (≥3 episodes)
Physical and Somatic Therapies
  • Exercise: ≥150 min/week moderate aerobic exercise — comparable effect to antidepressants for mild-moderate depression (Lancet Psychiatry 2023)
  • ECT (Electroconvulsive Therapy) — most effective treatment for severe/psychotic depression and treatment resistance; requires anaesthesia; referral to public or private psychiatric facility
  • rTMS (Repetitive Transcranial Magnetic Stimulation) — non-invasive; for treatment-resistant depression; increasingly available in Australian centres; Medicare Benefits Schedule rebate available
  • Light therapy (10,000 lux) — effective for seasonal affective disorder (SAD); 30 min each morning in winter

Antidepressant Prescribing Pearls

💡
  • Always check for potential bipolar disorder before prescribing — ask specifically about past manic/hypomanic episodes.
  • Explain the 2–4 week onset of action and that initial side effects (GI upset, headache, jitteriness) are usually transient.
  • Commit to a therapeutic trial of ≥6 weeks at adequate dose before declaring non-response.
  • Continue treatment for ≥6–12 months after remission of first episode; ≥2 years or indefinite for recurrent episodes (≥3 episodes).
  • Taper SSRIs/SNRIs over ≥4 weeks when discontinuing — do not stop abruptly (discontinuation syndrome: dizziness, nausea, "brain zaps," irritability).
  • Serotonin syndrome risk: educate patients about symptoms (agitation, hyperthermia, clonus, diaphoresis) — especially with concurrent use of tramadol, triptans, or MAOIs.
  • Monitor for activation/suicidality in the first 4 weeks, especially in those aged <25 years — schedule weekly follow-up.

Monitoring and Follow-Up Schedule

Baseline
PHQ-9, DASS-21, FBC, TSH, eGFR, LFTs, B12, vitamin D. Discuss diagnosis, treatment options, side effects, and realistic expectations. Develop safety plan if any suicidal ideation. Arrange GP Mental Health Treatment Plan if psychotherapy needed.
Week 1–2
Phone or telehealth check — assess tolerability, side effects, any emergence of suicidality (especially <25 yrs). Reinforce medication adherence. Address concerns.
Week 4
Face-to-face review — repeat PHQ-9. Assess early response. If minimal improvement at adequate dose → increase dose or consider switch.
Week 6–8
Formal response assessment — ≥50% reduction in PHQ-9 = response. No response at adequate dose for ≥6 weeks → switch antidepressant (different class preferred) or augment.
Week 12
Remission assessment (PHQ-9 <5). If remitted → continue current dose for ≥6–12 months. If partial response → optimise dose, add psychotherapy, consider augmentation.
Months 3–9
Monthly to bimonthly review. Ongoing relapse prevention. Reinforce lifestyle (exercise, sleep, diet, alcohol reduction, social connection). Monitor for side effects.
Month 12+
If sustained remission ≥6–12 months → discuss gradual taper. Single episode: taper over 2–4 months with close monitoring. Recurrent episodes (≥3): consider indefinite maintenance.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health
Burden of disease
Aboriginal and Torres Strait Islander peoples experience depression at 2–3 times the rate of non-Indigenous Australians (AIHW 2022). Suicide is the fifth leading cause of death overall for Indigenous Australians and the leading cause for those aged 15–34. The rate of suicide for Indigenous Australians is approximately twice that of non-Indigenous Australians, with youth suicide rates in some remote communities among the highest in the world.
Social and cultural determinants
Depression in Indigenous communities is inseparable from the impacts of intergenerational trauma, colonisation, Stolen Generations, racism, socioeconomic disadvantage, overcrowded housing, incarceration, and disconnection from Country and culture. The social and emotional wellbeing (SEWB) framework — which includes connection to body, mind and emotions, family and kinship, community, culture, Country, and spirituality — is preferred over the Western biomedical model of depression.
Culturally safe assessment
Use culturally validated tools where available. The K-10 has been validated for use in Indigenous populations and is used in the Aboriginal and Torres Strait Islander health check (MBS Item 715). The PHQ-9 may be used but should be administered in a culturally sensitive manner with awareness that distress may be expressed differently (e.g. somatic complaints, "feeling worried," "feeling shame"). Engage Aboriginal and Torres Strait Islander health workers and liaison officers in assessment and management.
Access barriers
Significant barriers to mental health care include geographic remoteness (limited specialist and psychologist access), stigma surrounding mental illness, shortage of culturally competent providers, distrust of mainstream health systems, and limited availability of bulk-billing psychology services. Telehealth has improved access but requires reliable internet and digital literacy, which remain inconsistent in remote communities.
Preferred approaches
Trauma-informed, strengths-based, and culturally grounded approaches are essential. Aboriginal Community Controlled Health Organisations (ACCHOs) deliver holistic, culturally safe care and should be the preferred provider where available. yarning circles, social and emotional wellbeing programs, cultural healing camps, art therapy, and on-Country activities have demonstrated benefit. The Gayaa Dhuwi (Proud Spirit) Australia declaration advocates for culturally informed mental health services. Programs such as the AIMhi Stay Strong app and the Integrated Team Care (ITC) programme support culturally appropriate mental health care in primary care settings.
Suicide prevention
Community-led suicide prevention strategies are critical. The National Aboriginal and Torres Strait Islander Suicide Prevention Strategy emphasises self-determination, community ownership, and local solutions. 13YARN (13 92 76) is a crisis line staffed by Aboriginal and Torres Strait Islander peoples. Gatekeeper training programs (e.g. YAM — Youth Aware of Mental Health) have been implemented in some communities. Means restriction and post-attempt follow-up are essential components of suicide prevention.
Prescribing considerations
Medication adherence may be affected by cultural factors, health literacy, pharmacy access in remote communities, and concerns about side effects. Use plain language explanations. Sertraline and escitalopram remain first-line. Ensure regular follow-up (use of Patient-Assisted Transport Scheme for remote patients accessing specialist services). Review concurrent medications and alcohol use. Long-acting injectable antipsychotics may be preferred for psychosis-related depression in some settings where oral adherence is challenging.

📚 References

  1. 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text rev (DSM-5-TR). Arlington, VA: APA; 2022.
  2. 2. Australian Bureau of Statistics. National Study of Mental Health and Wellbeing, 2020–2022. ABS Cat. No. 4327.0. Canberra: ABS; 2022.
  3. 3. Australian Institute of Health and Welfare. Suicide and self-harm monitoring. AIHW; 2023. Available from: https://www.aihw.gov.au/suicide-self-harm-monitoring
  4. 4. The Royal Australian College of General Practitioners. Mental health — a guide for health professionals in general practice. RACGP; 2023.
  5. 5. Productivity Commission. Mental Health, Inquiry Report No. 95. Canberra: Productivity Commission; 2020.
  6. 6. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613.
  7. 7. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–786.
  8. 8. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294(16):2064–2074.
  9. 9. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19(2):256–264.
  10. 10. Glassman AH, O'Connor CM, Califf RM, et al. Sertraline treatment of major depression in patients with acute MI or unstable angina (SADHART). JAMA. 2002;288(6):701–709.
  11. 11. Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet. 2018;391(10128):1357–1366.
  12. 12. Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry. 2021;55(1):7–117.
  13. 13. Australian Government Department of Health and Aged Care. Clinical Practice Guidelines: Pregnancy Care. Canberra: Commonwealth of Australia; 2019 (updated 2020).
  14. 14. Dudgeon P, Milroy H, Walker R (eds). Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice. 2nd ed. Canberra: Commonwealth of Australia; 2014.
  15. 15. Gayaa Dhuwi (Proud Spirit) Australia. Gayaa Dhuwi (Proud Spirit) Declaration. Canberra; 2020. Available from: https://gayaadhuwi.org.au
  16. 16. Cuijpers P, Noma H, Karyotaki E, Cipriani A, Furukawa TA. Effectiveness and acceptability of cognitive behavior therapy for depression: a systematic review and meta-analysis of individual patient data. World Psychiatry. 2019;18(3):269–277.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).