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Clinical Pathway

Depression — Stepped Care Pathway

Match treatment to severity; review at 4 weeks

Field: Mental HealthCode: MH-05Updated: June 2026Reference: RANZCP 2020 / RACGP
Match intensity of care to PHQ-9 severity. Around a third of patients remit on their first antidepressant trial — expect to adjust the plan. Treatment-resistant = failure of two adequately dosed antidepressant trials, not one disappointing review.

Stepped care by severity (PHQ-9)

By PHQ-9 band.

1
Mild (5–9): watchful waiting, lifestyle measures (sleep, exercise, alcohol), self-help/online CBT; review in 2–4 weeks.
2
Moderate (10–14): Mental Health Treatment Plan + psychological therapy (CBT); consider an antidepressant if preferred or prior good response.
3
Moderately severe (15–19): psychological therapy + antidepressant together; review at 2 and 4 weeks.
4
Severe (20–27): antidepressant + psychological therapy; consider psychiatry input; urgent pathway if safety risk.
5
Treatment-resistant / crisis: refer psychiatry; consider augmentation or ECT pathway.
Choosing the antidepressant. First-line agent depends on patient profile (pregnancy, cardiac disease, age, comorbid pain, prior response) — see MH-05B for the choice, switching and stopping detail.

Initiation — what to tell the patient

Mood effects usually take 2–4 weeks to start, up to 6–8 weeks for full response. Early nausea/headache/insomnia commonly settle within 1–2 weeks. Sexual side-effects are common and often dose-related — ask directly, patients rarely volunteer this. In adolescents and young adults, suicidal thinking can transiently increase in the first 1–4 weeks — flag this and arrange early review.

Monitoring schedule

  • Week 1–2: brief check (phone or short consult) — tolerability and safety/suicide-risk check, especially <25yo.
  • Week 4: full review with repeat PHQ-9 — optimise dose if partial response.
  • Week 8–12: repeat PHQ-9 — consider switching if no response despite an adequate trial (see MH-05B).
  • Ongoing: 3-monthly while stable; continue 6–12 months after remission of a first episode, longer if recurrent.
Mental health care planning. An MBS Mental Health Treatment Plan (e.g. item 2715) supports Better Access psychology sessions, but eligibility rules changed from Nov 2025 (MyMedicare practice/usual-GP linkage) — see MH-08 for the full pathway and confirm the current item number at mbsonline.gov.au.

Safety

  • Suicidality can transiently rise in adolescents/young adults in the first 1–4 weeks — monitor closely.
  • Anxiety coexists in roughly half of patients — screen for and treat both.
  • Continue 6–12 months after remission (longer if recurrent) — don't stop early.
  • Confirm no undisclosed MAOI or interacting drug before starting (see MH-05B).

Red flags / refer

  • Treatment-resistant — failed two adequately dosed antidepressant trials.
  • Bipolar features or psychosis suspected before starting an antidepressant.
  • Significant suicide risk — same-day psychiatric/crisis assessment.
  • Depression in pregnancy or postpartum needing specialist input; consider ECT referral pathway for severe or treatment-resistant illness.

MH-05 v1.0 · Reviewed Jun 2026 · Review Jun 2027

For health-professional use. Stepped care adapted from RANZCP's 2020 mood disorders guideline (most recent version) and RACGP. Antidepressant choice, switching & stopping — see MH-05B. Mental health care-plan items — see MH-08; confirm at mbsonline.gov.au.