# Major depressive disorder (mild-to-moderate) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: eMC SmPC, Efexor XL 150 mg prolonged release capsules (Viatris), sections 4.1 and 4.2 · Fluoxetine 20 mg Capsules SmPC section 4.2 Posology and method of administration (eMC product 11909) · LUSTRAL ® 50 mg film coated tablets SmPC section 4.2 Posology and method of administration (eMC product 1070) - Verified date: 2026-08 ## Verified against - eMC SmPC, Efexor XL 150 mg prolonged release capsules (Viatris), sections 4.1 and 4.2 - Fluoxetine 20 mg Capsules SmPC section 4.2 Posology and method of administration (eMC product 11909) - LUSTRAL ® 50 mg film coated tablets SmPC section 4.2 Posology and method of administration (eMC product 1070) - Major Depressive Disorder - disease-level clinical article (depression-clinical.txt) ## Treatment metadata - Fluoxetine — 20 mg — oral.solid - Sertraline — 50 mg — oral.solid - Referral & safety-netting (no drug therapy) - Venlafaxine — 75 mg — oral.solid ## Complete treatment card ```text MAJOR DEPRESSIVE DISORDER (MILD-TO-MODERATE) Sources: eMC SmPC, Efexor XL 150 mg prolonged release capsules (Viatris), sections 4.1 and 4.2 · Fluoxetine 20 mg Capsules SmPC section 4.2 Posology and method of administration (eMC product 11909) · LUSTRAL ® 50 mg film coated tablets SmPC section 4.2 Posology and method of administration (eMC product 1070) Review status: REVIEWED against eMC SmPC, Efexor XL 150 mg prolonged release capsules (Viatris), sections 4.1 and 4.2, Fluoxetine 20 mg Capsules SmPC section 4.2 Posology and method of administration (eMC product 11909), LUSTRAL ® 50 mg film coated tablets SmPC section 4.2 Posology and method of administration (eMC product 1070), Major Depressive Disorder - disease-level clinical article (depression-clinical.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (11) - Low mood that will not lift, or losing interest and pleasure in things that used to be enjoyable [low mood] - Feeling guilty, or feeling worthless - No energy, and concentration that has gone - Appetite has changed, in either direction - Movement and speech slowed down, or the opposite - restless and unable to settle [irritability] - Sleep is disturbed - too little, too much, or broken - Thoughts of suicide, which must be asked about directly at every visit - Five of these nine are needed, and one of the five must be the low mood or the lost pleasure, and it must be costing them socially or at work [low mood] - In children and teenagers the mood may look irritable rather than sad [irritability] - Many arrive at the GP with a physical complaint instead, and never reach a mental health service - In roughly half of cases the patient denies feeling depressed, and it is the family or the employer who brings them, having noticed the withdrawal and the drop in activity SIGNS - what you find (5) - There is no blood test for it - the diagnosis rests on the history and the mental state examination - The mental state examination is the central piece of the assessment, not a formality - Examine the patient properly, nervous system included, before settling on a psychiatric label - What the family or a friend tells you is part of the assessment, not an optional extra - Take the history wide: medical, family, social and substance use, alongside the symptoms themselves TESTS (5) - Bloods do not make the diagnosis - they are there to exclude a physical cause - The PHQ-9 is the primary-care instrument: nine questions the patient answers, matching the diagnostic criteria - A PHQ-9 of 10 or more, out of 27, points to the diagnosis - Hospitals use the Hamilton scale instead, and score only its first 17 items - Other scales in use are the Montgomery-Asberg, the Beck inventory, the Zung and the Raskin IF NOT THIS - what else fits (12) - Bipolar disorder - a past manic or hypomanic episode excludes this diagnosis and must be asked for - Longer-running low mood: dysthymia, or cyclothymia - Grief, or an adjustment reaction to something that has happened - Schizoaffective disorder or schizophrenia, where the mood problem is not the whole picture - An anxiety disorder, or an eating disorder - Neurological disease: stroke, multiple sclerosis, a subdural bleed, epilepsy, Parkinson or Alzheimer disease - Hormonal disease: diabetes, the thyroid, the adrenal glands - A metabolic upset - a high calcium or a low sodium - The drugs they are already on, or coming off: steroids, blood-pressure drugs, anticonvulsants, antibiotics, sedatives, alcohol, stimulant withdrawal - A deficiency: vitamin D, B12, B6, iron or folate - Infection - HIV and syphilis both do this - An underlying cancer Score PHQ-9 - How severe is this depression? Source StatPearls "Major Depressive Disorder" - disease-level clinical article Status traced to the source above 1. FLUOXETINE [1st line] Adult 20 mg once daily in morning, titrate after 3-4 weeks up to max 60 mg daily - Long-term (continue 6 months post-remission) Peds 8 to 17 years: 10 mg once daily, titrated to 20 mg - under specialist CAMHS supervision (Child 8-17 yrs (specialist CAMHS supervision): 10 mg once daily, titrate to 20 mg) Source Fluoxetine 20 mg Capsules SmPC section 4.2 Posology and method of administration (eMC product 11909) Why First-line SSRI with activating profile and long half-life (less discontinuation syndrome) Caution Warn patient that onset of antidepressant effect takes 2-4 weeks. Monitor closely for suicidal ideation in young adults during initial weeks. Do not combine with MAO inhibitors or serotonergic drugs (serotonin syndrome). Egypt FLOROSIN 20MG 10 CAPS. UP PHARMA 11.00 EGP (1.10/unit) PHILOZAC 20MG 10 CAPS. AMOUN 11.00 EGP (1.10/unit) FLUOXETINE 20 MG 10 CAPS. MISR 18.60 EGP (1.86/unit) ELEVAMOOD 20 MG 28 CAPS. UNIPHARMA 56.00 EGP (2.00/unit) OCTOZAC 20MG 10 CAPS. OCTOBER PHARMA 21.60 EGP (2.16/unit) PHILOZAC 20MG 30 CAPS. AMOUN 75.00 EGP (2.50/unit) PROZAC 20MG 14 CAPS. ELI LILLY 118.00 EGP (8.43/unit) FLUOXETINE 20 MG H.G.CAPS. SIGMA 8.00 EGP 2. SERTRALINE [1st line] Adult 50 mg once daily, titrate by 50 mg steps at 2-3 week intervals to max 200 mg daily - Long-term (continue 6 months post-remission) Peds Pediatric use restricted to OCD under specialist supervision Choice Alternatives, both first-line SSRIs. Sertraline is preferred where cardiovascular disease or age is a factor, which covers most of the patients started on one. Source LUSTRAL ® 50 mg film coated tablets SmPC section 4.2 Posology and method of administration (eMC product 1070) Why Preferred SSRI in patients with cardiovascular disease or elderly Caution Do not combine with MAO inhibitors (risk of fatal serotonin syndrome). Monitor closely for suicidal ideation during initial weeks (especially in patients <25 years). Gastrointestinal side effects (nausea, diarrhea) are common initially. Taper dose gradually when discontinuing to prevent withdrawal symptoms. Caution with antiplatelets or anticoagulants (increased bleeding risk). Egypt OPIRALINE 50 MG 20 F.C. TABS. EL-OBOUR 29.00 EGP (1.45/unit) AGRELOCIT 50 MG 20 TAB. MEMPHIS > ATM... 34.80 EGP (1.74/unit) DEPR-STAT 50MG 10 CAPS. MEMPHIS 21.60 EGP (2.16/unit) SESERINE 50MG 30 TAB. ADWIA 75.00 EGP (2.50/unit) SERPASS 50MG 30 F.C.TAB. GLOBAL NAPI P... 102.00 EGP (3.40/unit) SIRTO 50MG 10 F.C. TABS. HI-PHARM 34.00 EGP (3.40/unit) MOODAPEX 50 MG 30 F.C.TAB. MULTI-APEX 111.00 EGP (3.70/unit) LUSTRAL 50 MG 20 F.C.TABS. VIATRIS 136.00 EGP (6.80/unit) 3. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Major Depressive Disorder - disease-level clinical article (depression-clinical.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Evaluation for suicidal or homicidal ideation is mandatory at each visit. 4. VENLAFAXINE [2nd line] Adult Prolonged release: 75 mg once daily. Increase at intervals of 2 weeks or more (not less than 4 days) up to a maximum of 375 mg/day - Continue for at least 6 months after remission; taper over at least 1-2 weeks, and considerably longer in practice, when stopping Peds Not recommended in children and adolescents - trials failed to demonstrate efficacy and there were more self-harm and hostility events. Source eMC SmPC, Efexor XL 150 mg prolonged release capsules (Viatris), sections 4.1 and 4.2 Why 30 live products. The condition currently holds two SSRIs and nothing else - venlafaxine is the standard next step for a patient who has not responded to an adequate SSRI trial, and the same SmPC also covers generalised anxiety, social anxiety and panic disorder. Caution Dose-related rise in blood pressure. Measure blood pressure before starting and after each increase, and think hard before exceeding 150 mg/day in a hypertensive patient. Withdrawal reactions are more severe and more common than with the fluoxetine and sertraline already listed - never stop abruptly, and warn the patient before they start. More toxic in overdose than an SSRI - weigh this where there is self-harm risk, and limit the quantity dispensed. Monitor closely for emergent or worsening suicidal thinking in the first weeks and in anyone under 25. Do not combine with a monoamine oxidase inhibitor - leave 14 days between them. Efexor XL 150 mg hard prolonged release capsules SmPC section 4.5 (eMC product 1219): "Venlafaxine must not be used in combination with irreversible non-selective MAOIs." and "Venlafaxine must not be initiated for at least 14 days after discontinuation of treatment with an irreversible non-selective MAOI." The label also asks for 7 days the other way round, before an MAOI is started; the card's single 14-day gap is the more restrictive of the two. Do not add to the fluoxetine or sertraline in this row - switch, with an appropriate cross-taper. Venlafaxine can cause QT prolongation and arrhythmia, chiefly in overdose. Egypt VENOXOR 75 MG 28 TABS. UNIPHARMA CO.... 82.00 EGP (2.93/unit) VENLAFAXINE 75MG SR 7 CAPS. GLOBAL NAPI P... 21.00 EGP (3.00/unit) VEXAMOD 75MG SR 10 CAPS SIGMA 30.00 EGP (3.00/unit) GLOBEXOR 75MG 14 CAPS. GLOBAL NAPI P... 48.00 EGP (3.43/unit) IDIXOR XR 75 MG 7 CAPS. INTERNATIONAL... 32.50 EGP (4.64/unit) EFEXOR XR 75MG 14 CAPS. WYETH AYERST ... 158.00 EGP (11.29/unit) EFFEGAD 75 MG 30 E.R. CAPS. EPCI > HIKMA ... 90.00 EGP VENLLAMASH 75 MG 30 EXT. REL. CAPS. MASH PREMIERE 159.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)