Depression & Adjustment Disorder

Diagnostic Criteria

Major Depressive Disorder (MDD)

• Core Features: Depressed mood or loss of interest/pleasure (anhedonia).

• Duration: At least 2 weeks of symptoms.

• Diagnostic Requirement: At least 5 of the SIGECAPS symptoms (including depressed mood or anhedonia) nearly every day:

  1. Sleep disturbance (insomnia or hypersomnia)

  2. Interest (loss of interest or pleasure)

  3. Guilt / feelings of worthlessness

  4. Energy (lack of energy, fatigue)

  5. Concentration difficulties

  6. Appetite changes (increased or decreased)

  7. Psychomotor changes (agitation or retardation)

  8. Suicidality (recurrent thoughts of death, suicidal ideation or attempts)

• Functional Impact: Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Persistent Depressive Disorder

• Previously known as dysthymia or chronic major depressive disorder.

• Criteria:

  • Depressed mood for most of the time over at least 2 years in adults (1 year in adolescents).

  • No symptom-free period exceeding 2 months.

  • At least 2 additional symptoms from the SIGECAPS cluster.

Adjustment Disorder

• Onset: Emotional or behavioural symptoms arising within 3 months of an identifiable stressor.

• Duration: Symptoms usually resolve within 6 months after the stressor (or its consequences) ends.

• Functional Impact: Impairs functioning but does not meet criteria for a major mood disorder (e.g. MDD).

Management

Mild Depression

• Psychological Therapy

  • Cognitive Behavioural Therapy (CBT) or counselling is preferred over medication.

  • Other modalities may include interpersonal therapy or problem-solving therapy, depending on local availability and patient preference.

• Lifestyle Changes

  • Regular exercise (e.g. 150 minutes of moderate-intensity aerobic activity per week).

  • Adequate sleep hygiene, healthy diet, reduced alcohol intake.

  • Consider relaxation techniques (e.g. mindfulness, meditation).

• Monitoring

  • Provide ongoing support and review symptoms regularly to detect any deterioration.

Moderate Depression

• Combination Treatment

  • Psychological therapy + pharmacotherapy is often beneficial, guided by patient preference and clinical judgement.

• Pharmacotherapy

  • SSRIs (e.g. sertraline, fluoxetine) are first-line medication choices.

  • Start at a low-to-moderate dose and titrate according to response and tolerability.

• Follow-Up

  • Regularly monitor for improvement, side effects, and adherence (e.g. every 2–4 weeks initially).

  • Manage comorbid conditions (e.g. anxiety, substance misuse, chronic pain).

Severe Depression

• Pharmacotherapy

  • SSRIs (e.g. sertraline, fluoxetine) remain first-line.

  • Consider augmentation (e.g. adding an atypical antipsychotic) if there are psychotic features or partial response.

• Safety and Suicidality

  • Hospital admission may be required if there is high risk of suicide, severe self-neglect, or inability to function at home.

• Electroconvulsive Therapy (ECT)

  • Considered for treatment-resistant cases or when there is an urgent, life-threatening scenario (e.g. severe suicidality, refusal of food and fluids).

Adjustment Disorder

• Psychological Therapy

  • CBT or counselling to support coping strategies and stress management.

• Lifestyle Modifications

  • Encourage aerobic exercise (150 minutes per week).

  • Engage in hobbies, social connections, and supportive relationships.

  • Emphasise sleep hygiene and healthy eating.

• Pharmacotherapy

  • Avoid routine SSRIs unless symptoms progress to or overlap significantly with major depression.

  • A short course of anxiolytic medication (e.g. benzodiazepines) may be considered briefly if anxiety is severe, but generally limit to a maximum of 2 weeks due to dependence risk.

Additional Considerations

1. Patient Education & Psychoeducation

   • Discuss the nature of depression and/or adjustment disorder, likely duration, and the importance of adherence to therapy.

   • Reinforce that improvement may take several weeks.

2. Monitoring & Review

   • Arrange regular follow-up to assess clinical response, medication side effects, and overall functioning.

   • If inadequate response after 6–8 weeks of treatment, re-evaluate diagnosis, consider dose adjustment, switching medication, or adding psychotherapy.

3. Risk Management

   • Always assess suicidal ideation and risk factors (e.g. past attempts, comorbid psychiatric conditions, social isolation).

   • Involve crisis teams or inpatient services when needed.

4. Holistic Approach

   • Address comorbidities (e.g. anxiety disorders, substance use, chronic pain).

   • Consider social determinants of health: financial stress, relationship issues, housing insecurity.

5. Referral

   • Refer to mental health specialists (psychiatrists, psychologists) if complex presentations, treatment resistance, severe functional impairment, or high suicide risk.