Depression — MSF Clinical guidelines — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Clinical guidelines — Diagnosis and treatment manual › Chapter 11: Mental disorders in adults · Médecins Sans Frontières, Current online edition (last updated July 2022)

MSF guidance on diagnosing and managing major depressive disorder in humanitarian and resource-limited settings.

In one sentenceDiagnose depression with ≥2 weeks of sadness/anhedonia plus ≥4 additional symptoms; treat severe or persistent moderate depression with SRIs (fluoxetine 20 mg daily, maximum 40 mg; sertraline in pregnancy) plus counselling; monitor suicide risk closely in first 2-3 weeks.

Issuer: Médecins Sans Frontières
Edition: Current online edition (last updated July 2022)
Audience: Physicians, nurses, and clinical officers in MSF programmes and similar settings
Evidence: Expert consensus based on MSF field experience
Reviewed: 22 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 22 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This MSF clinical guideline provides diagnostic criteria and treatment algorithms for major depressive disorder in humanitarian contexts. Depression is diagnosed when pervasive sadness and/or loss of interest in pleasurable activities is present for at least two weeks, accompanied by at least four of eight additional symptoms including sleep disturbance, appetite change, psychomotor changes, fatigue, concentration difficulties, guilt, despair, or suicidal thoughts. Cultural variations in presentation are emphasised, with some patients expressing somatic rather than psychological complaints.

Management prioritises ruling out organic causes (hypothyroidism, Parkinson’s disease) and medication adverse effects (corticosteroids, cycloserine, efavirenz, mefloquine). Pharmacological treatment is mandatory for severe depression (PHQ-9 score >19, severe functional impairment, psychotic symptoms, or suicidal risk) and should be considered for moderately severe depression (PHQ-9 score 15-19) if counselling fails or by patient preference. Serotonin reuptake inhibitors (SRIs) are preferred, with fluoxetine as first-line (20 mg alternate days for one week, then daily, maximum 40 mg daily) except in pregnancy where sertraline is preferred.

Treatment requires a 9-month commitment to ensure adequate follow-up. Close monitoring is essential in the first 2-4 weeks due to increased suicide risk before antidepressant effects occur (2-3 weeks for SRIs, 4 weeks for amitriptyline). Adjunctive anxiolytics may be needed initially. Treatment must be tapered gradually over 4 weeks to prevent withdrawal. Special attention is given to depression in chronic infectious diseases (HIV, tuberculosis) where it negatively impacts treatment adherence, and to perinatal depression requiring specific medication choices to protect the neonate.

Key points

For clinicians — doses and thresholds as stated in the guideline

Diagnosis requires pervasive sadness and/or loss of interest for ≥2 weeks plus ≥4 of 8 additional symptoms (appetite change, sleep disturbance, psychomotor changes, fatigue, concentration difficulties, guilt, despair, suicidal thoughts).
Pharmacological treatment is mandatory for severe depression (PHQ-9 score >19, severe functional impairment, psychotic symptoms, or suicidal risk) and should be considered for moderately severe depression (PHQ-9 score 15-19) after 3 failed counselling sessions.
First-line: fluoxetine 20 mg on alternate days for 1 week, then once daily for 3 weeks, then increase if necessary (maximum 40 mg daily); avoid in severe anxiety or immobilised patients.
Alternative SRIs: paroxetine 10 mg once daily for 3 days, then 20 mg once daily (maximum 40 mg daily); sertraline 25 mg once daily for 3 days, then 50 mg once daily (maximum 100 mg daily).
If SRIs unavailable: amitriptyline starting 25 mg once daily at bedtime, increase over 8-10 days to 75 mg once daily (maximum 150 mg daily); reduce dose by half in older patients; therapeutic dose is close to lethal dose.
Adjunctive treatment for first 2 weeks: hydroxyzine 25-50 mg twice daily (maximum 100 mg daily) or promethazine 25-50 mg once daily at bedtime; if no improvement after 1 week, change to diazepam 2.5-5 mg twice daily for maximum 2 weeks.
Antidepressant effect delayed 2-3 weeks for SRIs, 4 weeks for amitriptyline; suicide risk may increase during this period, especially with fluoxetine; dispense only 1 week of medication at a time during first 2-4 weeks.
Perinatal depression: use sertraline as first-line in severe post-partum depression or pregnancy; avoid fluoxetine during breastfeeding and paroxetine during pregnancy; taper treatment gradually over 4 weeks to prevent withdrawal.

Antidepressant dosing regimens

Table extracted from the guideline

Medication	Initial dose	Titration	Maintenance dose	Maximum dose	Special notes
Fluoxetine	20 mg alternate days	After 1 week: 20 mg once daily for 3 weeks	20 mg once daily	40 mg daily	Avoid in severe anxiety or immobilised patients; avoid during breastfeeding
Paroxetine	10 mg once daily	After 3 days: 20 mg once daily for 3 weeks	20 mg once daily	40 mg daily	Especially if severe anxiety present; avoid during pregnancy; high risk of withdrawal
Sertraline	25 mg once daily	After 3 days: 50 mg once daily for 3 weeks	50 mg once daily	100 mg daily	Preferred during pregnancy and breastfeeding
Amitriptyline	25 mg once daily at bedtime	Increase over 8-10 days to 75 mg	75 mg once daily	150 mg daily	If SRIs unavailable; reduce dose by half in elderly; therapeutic dose close to lethal dose

Source: Médecins Sans Frontières, Depression — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“Pharmacological treatment should always be offered, along with counseling, to patients with severe depression (Patient Health Questionnaire-9 (PHQ-9) score > 19; severe functional impairment, psychotic symptoms, and/or suicidal risk).”

— Médecins Sans Frontières, Depression — MSF Clinical guidelines, Management section (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute of Georgia, I recognise the critical importance of this MSF guideline for primary care settings across Georgia and the South Caucasus. Mental health remains significantly under-addressed in our region despite high prevalence, and depression is particularly underdiagnosed in patients with chronic conditions like tuberculosis and HIV. The guideline's emphasis on PHQ-9-based stepped care and the clear threshold that severe depression (PHQ-9 >19) always requires pharmacological treatment alongside counselling provides a practical framework that can be integrated into Georgia's expanding primary healthcare network under the Universal Healthcare Programme. I would particularly stress to Georgian clinicians the need for close monitoring during the first 2-4 weeks of antidepressant treatment when suicide risk may actually increase before therapeutic effects emerge—this requires weekly dispensing and clear safety planning, which demands time and coordination that are realistic implementation challenges in busy polyclinics with limited mental health staffing. The guidance on sertraline as the preferred agent during pregnancy and breastfeeding is especially relevant given that post-partum depression is more common than depression during pregnancy itself, yet often goes unrecognised in our maternal health services.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 22 Oct 2026

Applicability

Georgia and the South Caucasus

This guideline is highly relevant for Georgia and the South Caucasus region where mental health services remain under-resourced and stigma remains a barrier to care. Georgia’s Universal Healthcare Programme covers some mental health services, but primary care integration remains limited. The emphasis on screening with PHQ-9 and stepped-care approaches aligns with WHO mhGAP implementation efforts in the region. National programmes would need to consider cultural presentations of depression in Georgian, Armenian, and Azerbaijani populations, ensure availability of preferred SRIs (fluoxetine, sertraline, paroxetine) in primary care formularies, and develop protocols for suicide risk assessment and management within existing referral pathways. The guideline’s focus on depression comorbid with HIV and tuberculosis is particularly relevant given ongoing TB burden in the region and the need to integrate mental health into infectious disease programmes.

Questions this guideline answers

Quick answers

When is pharmacological treatment mandatory for depression?

Pharmacological treatment must always be offered, along with counselling, to patients with severe depression: PHQ-9 score >19, severe functional impairment, psychotic symptoms, and/or suicidal risk. For moderately severe depression (PHQ-9 score 15-19), consider pharmacological treatment if no improvement after 3 counselling sessions or if the patient prefers it from the outset.

Why must medication be dispensed weekly during the first 2-4 weeks of treatment?

During the first 2-3 weeks before the antidepressant effect occurs (4 weeks for amitriptyline), anxiety may be exacerbated and the risk of suicide may increase, especially with fluoxetine. Dispensing only one week of medication at a time, or entrusting administration to someone in the patient's close entourage, reduces access to potentially lethal quantities during this high-risk period.

Which antidepressant should be used during pregnancy and breastfeeding?

Sertraline is preferred during both pregnancy and breastfeeding. If a woman on fluoxetine plans to breastfeed, consider switching to another SRI at least 3 weeks before expected delivery to reduce adverse effects in the neonate. Avoid fluoxetine during breastfeeding and avoid paroxetine during pregnancy.

What should be done if there is no improvement after 4 weeks of treatment at optimal dose?

If response is inadequate after 4 weeks at optimal dose, replace with another SRI (no medication-free interval needed). If major symptoms have not improved after a month, increase to maximum dose and assess after 2 weeks. If still no improvement, refer to a psychiatrist if possible; if not, try a different antidepressant.

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Depression — MSF Clinical guidelines

What this guideline says

Key points

Antidepressant dosing regimens

From the guideline