Depression and Other Mood Disorders

Last updated 1 Jun 2026 · Psychiatry

📋 Key Information Summary

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DSM-5 classifies depressive disorders as major depressive disorder (MDD), persistent depressive disorder (dysthymia), disruptive mood dysregulation disorder, premenstrual dysphoric disorder, and substance/medication-induced depressive disorder — each with specific diagnostic criteria and duration thresholds.
Severity grading (mild, moderate, severe) is based on symptom count, functional impairment, and the presence of psychotic or melancholic features; severity dictates treatment intensity and setting.
First-line pharmacotherapy for MDD in Australian general practice is an SSRI (e.g., sertraline, escitalopram) — all PBS-listed as General Benefits — combined with psychotherapy (CBT, IPT) for moderate-to-severe disease.
Bipolar disorder (BD-I, BD-II, cyclothymia) must be distinguished from unipolar depression; misdiagnosis leads to antidepressant monotherapy, which risks manic switch. Mood stabilisers (lithium, valproate, lamotrigine) are the cornerstone of treatment.
Lithium remains first-line for BD-I maintenance; monitor serum levels (0.4–0.8 mmol/L for maintenance), renal function (eGFR), thyroid function (TSH), and calcium every 3–6 months once stabilised.
Perinatal depression affects ~1 in 7 Australian women; Edinburgh Postnatal Depression Scale (EPDS ≥13) is the recommended screening tool at 6–12 weeks postpartum and again at 6–12 months.
Sertraline is the preferred SSRI in breastfeeding (lowest infant plasma levels); avoid doxepin and lithium monotherapy in breastfeeding mothers.
Postnatal psychosis is a psychiatric emergency presenting within the first 2 weeks postpartum; requires immediate hospital admission, often under a Mother–Baby Unit.
Suicide risk assessment is mandatory at every consultation; use the Columbia-Suicide Severity Rating Scale (C-SSRS) or equivalent, and develop a safety plan. In crisis, contact Lifeline 13 11 14 or 000.
Aboriginal and Torres Strait Islander communities experience depression at 2–3 times the general population rate; culturally safe, trauma-informed care through ACCHOs and yarning-based approaches improves engagement.
Social determinants — housing, incarceration, grief, racism, Stolen Generations — must be addressed alongside pharmacotherapy; referral to social and emotional wellbeing (SEW) programs is essential.
Stepped care model (Australian Government Better Access): Step 1 (watchful waiting), Step 2 (low-intensity CBT, e.g., MindSpot, THIS WAY UP), Step 3 (face-to-face psychotherapy), Step 4 (specialist/complex care).

Introduction & Australian Epidemiology

Mood disorders — encompassing depressive disorders, bipolar disorders, and related conditions — are among the most common presentations in Australian general practice. They are the leading cause of non-fatal disease burden globally and contribute substantially to disability, lost productivity, and suicide.

In Australia, approximately 1 in 5 adults (4.2 million people) experienced a mental disorder in the past 12 months (2020–22 National Study of Mental Health and Wellbeing), with depressive episodes and anxiety disorders the most prevalent. Lifetime prevalence of major depressive disorder (MDD) in Australia is estimated at 10–15%, while bipolar disorder affects approximately 1.8–2.4% of the population (BD-I ~1%, BD-II ~0.8–1.1%).

Mood disorders disproportionately affect Aboriginal and Torres Strait Islander peoples, people in rural and remote areas, those experiencing socioeconomic disadvantage, and individuals with comorbid chronic disease. General practitioners (GPs) are the primary point of contact for the majority of Australians with mood disorders, and the gateway to the Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS (Medicare Benefits Schedule) initiative.

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Diagnostic caution: Up to 40% of patients initially diagnosed with unipolar depression are later reclassified as bipolar disorder — most commonly BD-II. Always screen for prior hypomanic or manic episodes before initiating antidepressant monotherapy.

Australian Burden of Disease

Metric	Value (Australia)	Source
12-month prevalence — any affective disorder	6.2% (~1.3 million)	ABS NSMHW 2020–22
Lifetime prevalence — MDD	10–15%	AIHW 2023
Lifetime prevalence — bipolar disorder	1.8–2.4%	Mitchell et al., 2011
Perinatal depression prevalence	~1 in 7 women (~14%)	COPE / PANDA
Deaths by suicide (2023)	3,214 (age-standardised rate 12.3 per 100,000)	ABS Causes of Death 2023
Proportion of suicide deaths with mood disorder	~40–60%	AIHW 2023

DSM-5 Classification & Severity Grading

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR, 2022) classifies mood disorders into two broad groups: depressive disorders and bipolar and related disorders. This represents a major change from DSM-IV, which grouped them together as "mood disorders."

DSM-5 Depressive Disorders

Disorder	Key Diagnostic Criteria	Duration
Major Depressive Disorder (MDD)	≥5 of 9 SIG E CAPS symptoms (depressed mood or anhedonia mandatory); clinically significant distress or functional impairment	≥2 weeks
Persistent Depressive Disorder (Dysthymia)	Depressed mood most days for ≥2 years (≥1 year in children/adolescents); ≥2 of: appetite change, sleep change, fatigue, low self-esteem, poor concentration, hopelessness	≥2 years (no symptom-free period >2 months)
Disruptive Mood Dysregulation Disorder (DMDD)	Severe recurrent temper outbursts (verbal/behavioural) grossly out of proportion; irritable/angry mood between outbursts in ≥2 settings	≥12 months (age 6–18 years)
Premenstrual Dysphoric Disorder (PMDD)	≥5 of 11 symptoms (mood lability, irritability, depressed mood, anxiety, decreased interest, difficulty concentrating, fatigue, appetite change, sleep change, physical symptoms, anger); must include ≥1 core mood symptom	Last week of luteal phase; remit within days of menses onset; present in most menstrual cycles over past year
Substance/Medication-Induced Depressive Disorder	Prominent mood disturbance temporally related to substance/medication; not better explained by independent depressive disorder	During or shortly after intoxication/withdrawal/exposure
Depressive Disorder Due to Another Medical Condition	Prominent mood disturbance aetiologically related to a medical condition (e.g., hypothyroidism, Cushing's, multiple sclerosis, stroke)	Variable

SIG E CAPS Mnemonic — 9 DSM-5 MDD Criteria

Letter	Symptom	Notes
S	Sleep disturbance	Insomnia or hypersomnia
I	Interest loss (anhedonia)	Core criterion — must be present
G	Guilt (excessive/inappropriate)	Often nihilistic in melancholic depression
E	Energy loss / fatigue	Nearly universal
C	Concentration impaired	Must assess in context (elderly → screen for delirium/dementia)
A	Appetite/weight change	Increase or decrease ≥5% body weight in 1 month
P	Psychomotor changes	Agitation or retardation — observable by others
S	Suicidality / thoughts of death	Must be actively assessed at every contact

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DSM-5 severity specifier: MDD is graded as mild (few symptoms beyond minimum, minor functional impairment), moderate (symptoms and functional impairment between mild and severe), or severe (most symptoms, markedly interferes with function). Additional specifiers include with anxious distress, with mixed features, with melancholic features, with atypical features, with psychotic features, with catatonia, with peripartum onset, and with seasonal pattern.

Severity Grading — Clinical Guide

Mild

Mild Depression

5–6 SIG E CAPS symptoms; minor functional impairment; able to work and maintain relationships with effort; no suicidal ideation with intent.

Setting: GP — watchful waiting (2 weeks) or low-intensity interventions (online CBT, behavioural activation); SSRI if persistent

Moderate

Moderate Depression

7–8 symptoms; clear functional impairment at work/home; may have passive suicidal ideation; ruminative worry; somatic symptoms common.

Setting: GP with structured psychotherapy referral (Better Access MBS items 80000–80020, 80100–80125); SSRI/SNRI initiated; review at 2, 4, 6 weeks

Severe

Severe Depression ± Psychotic Features

All or nearly all SIG E CAPS symptoms; marked functional impairment; active suicidal ideation with/without plan; possible psychotic features (mood-congruent delusions/hallucinations); catatonia.

Setting: Urgent psychiatric referral — hospitalisation may be required; combination antidepressant + antipsychotic or ECT for psychotic depression

Types of Depressive Disorders

Major Depressive Disorder (MDD)

MDD is the most common depressive disorder seen in general practice. Diagnosis requires ≥5 of 9 SIG E CAPS symptoms during the same 2-week period, representing a change from previous functioning, with at least one symptom being depressed mood or anhedonia.

Exclusion Criteria

Not attributable to the physiological effects of a substance or another medical condition (check thyroid, B12, folate, iron studies, cortisol)
Not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other psychotic disorders
No history of manic or hypomanic episodes (if present → bipolar disorder)

Persistent Depressive Disorder (Dysthymia)

Chronic low-grade depression lasting ≥2 years (≥1 year in children/adolescents). Many patients with persistent depressive disorder will have a superimposed MDD episode ("double depression"), which carries a worse prognosis. Treatment typically requires longer courses of antidepressant therapy and sustained psychotherapy.

Premenstrual Dysphoric Disorder (PMDD)

Affects 3–8% of menstruating women. Symptoms are confined to the late luteal phase and resolve within days of menses onset. First-line treatment is an SSRI — either continuously or luteal-phase-only dosing (e.g., fluoxetine 20 mg daily from day 14 to menses). Combined oral contraceptives containing drospirenone (e.g., Yaz®) are second-line.

Depressive Disorder Due to Another Medical Condition

Always exclude underlying medical causes before diagnosing a primary depressive disorder. Key conditions to screen:

Medical Condition	Screening Investigation	MBS Item
Hypothyroidism	TSH ± free T4	66721
Iron deficiency	FBC, ferritin, iron studies	66555
Vitamin B12 / folate deficiency	Serum B12, folate, homocysteine	66841 / 66847
Cushing's syndrome	24-hr urinary cortisol or overnight dexamethasone suppression test	66621
Multiple sclerosis	MRI brain (if neurological signs present)	63001
Stroke / vascular disease	Clinical history, CT/MRI	63001
Medication-induced (corticosteroids, beta-blockers, interferons, hormonal agents)	Medication review	N/A

Pharmacotherapy — Depressive Disorders

First-Line: SSRIs

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Sertraline

Zoloft® · Generic · SSRI

Adult dose 50 mg PO daily, titrate to 100–200 mg daily after 2–4 weeks if needed

Paediatric dose 13–17 years: start 25 mg PO daily for 1 week, then 50 mg daily; max 200 mg/day (TGA approved ≥13 years for OCD)

Renal adjustment No adjustment required

Hepatic adjustment Reduce dose or use with caution in severe hepatic impairment

Key interactions MAOIs (contraindicated); risk of serotonin syndrome with tramadol, triptans; CYP2D6 inhibitor

PBS status ✔ PBS General Benefit

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Escitalopram

Lexapro® · Generic · SSRI

Adult dose 10 mg PO daily, may increase to 20 mg daily after ≥1 week

Paediatric dose Not routinely recommended <18 years for MDD (TGA); limited evidence

Renal adjustment No adjustment required

Hepatic adjustment Max 10 mg daily in hepatic impairment

Key interactions MAOIs (contraindicated); QTc prolongation risk at high doses — avoid with other QTc-prolonging agents

PBS status ✔ PBS General Benefit

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Fluoxetine

Prozac® · Generic · SSRI

Adult dose 20 mg PO morning, may increase to 40–60 mg daily after several weeks

Paediatric dose 8–17 years: 10 mg/day for 1 week, then 20 mg/day; max 60 mg/day (TGA approved ≥8 years for MDD)

Renal adjustment No adjustment required

Hepatic adjustment Reduce dose or frequency in hepatic impairment

Key interactions Long half-life (active metabolite norfluoxetine t½ 4–16 days); washout ≥5 weeks before MAOI initiation

PBS status ✔ PBS General Benefit

Second-Line: SNRIs

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Venlafaxine

Efexor-XR® · Generic · SNRI

Adult dose 37.5–75 mg PO daily (XR); titrate to 150–225 mg daily. At doses ≥150 mg/day noradrenergic effect becomes clinically significant.

Renal adjustment Reduce dose by 25–50% if eGFR <30 mL/min

Hepatic adjustment Reduce dose by 50% in hepatic impairment

Key interactions Hypertension — monitor BP; discontinuation syndrome (taper over 2–4 weeks); MAOI contraindication

PBS status ✔ PBS General Benefit

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Duloxetine

Cymbalta® · Generic · SNRI

Adult dose 30 mg PO daily for 1 week, then 60 mg daily; max 120 mg/day

Renal adjustment Avoid if eGFR <30 mL/min

Hepatic adjustment Contraindicated in severe hepatic impairment

Key interactions Useful for comorbid neuropathic pain (PBS authority for this indication); monitor liver function

PBS status ✔ PBS General Benefit (depression); Authority Required (neuropathic pain)

Third-Line / Adjunct Agents

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Mirtazapine

Avanza® · Generic · NaSSA

Adult dose 15 mg PO nocte, titrate to 30–45 mg nocte

Renal adjustment Reduce dose if eGFR <30 mL/min

Key interactions Sedation (lower doses more sedating due to antihistaminic H1 effect); weight gain; useful for comorbid insomnia and appetite loss

PBS status ✔ PBS General Benefit

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Vortioxetine

Trintellix® · Multimodal serotonergic

Adult dose 10 mg PO daily; may increase to 20 mg daily

Renal adjustment No adjustment required

Key interactions Pro-cognitive effects (5-HT receptor modulation); nausea is most common AE; CYP2D6 interaction

PBS status PBS Authority Required — inadequate response to ≥2 antidepressants

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Black box warning (TGA): SSRIs and SNRIs carry a boxed warning regarding increased risk of suicidal thinking and behaviour in children, adolescents, and young adults (<25 years). Close monitoring (weekly for first 4 weeks, then fortnightly for 4 weeks, then at 12 weeks) is essential. In Australia, fluoxetine (≥8 years) and sertraline (≥13 years for OCD) are the only SSRIs with TGA paediatric approvals.

Non-Pharmacological Therapies

Cognitive Behavioural Therapy (CBT): First-line psychotherapy for mild-to-moderate MDD; ≥12 sessions typically required. Available via Better Access MBS items (up to 10 individual + 10 group sessions per calendar year, with GP Mental Health Treatment Plan — MBS item 2710/2712).
Interpersonal Therapy (IPT): Evidence-based for MDD, particularly effective in perinatal depression; focuses on role disputes, role transitions, grief.
Behavioural Activation: Structured re-engagement with rewarding activities; effective as standalone for mild–moderate depression.
Internet-based CBT (iCBT): MindSpot (free, government-funded), THIS WAY UP (low-cost), eCentreClinic — suitable for mild-to-moderate depression as Step 2 of stepped care.
Electroconvulsive Therapy (ECT): Most effective treatment for severe, treatment-resistant, or psychotic depression; requires specialist referral; available in public and private psychiatric facilities across Australia.

Treatment-Resistant Depression

Defined as failure to achieve remission after ≥2 adequate trials of antidepressants (adequate dose and duration of 6–8 weeks). Management steps:

Confirm diagnosis (exclude bipolar disorder, medical causes, substance use, personality factors)
Optimise dose and ensure adherence (check for non-compliance, side effects, drug interactions)
Switch to an antidepressant from a different class (e.g., SSRI → SNRI or mirtazapine)
Augment with lithium (250–500 mg nocte, target serum level 0.4–0.8 mmol/L), thyroid hormone (T3, liothyronine 20–25 mcg/day), or an atypical antipsychotic (aripiprazole 2–5 mg/day — PBS authority for augmentation)
Combine psychotherapy if not already engaged
Refer for specialist review — consider ECT, repetitive transcranial magnetic stimulation (rTMS), or ketamine/esketamine (Spravato® — TGA-approved, specialist use only)

Bipolar Disorder

Bipolar disorder is a chronic, relapsing condition characterised by episodes of mania (BD-I), hypomania (BD-II), and depression. It is frequently misdiagnosed as unipolar depression, with an average diagnostic delay of 5–10 years in Australia.

DSM-5 Bipolar Classification

Disorder	Key Features	Minimum Duration
Bipolar I Disorder	≥1 manic episode (elevated/irritable mood + ≥3 DIGFAST symptoms); may have depressive and hypomanic episodes; hospitalisation usually required for mania	Mania: ≥7 days (or any duration if hospitalised)
Bipolar II Disorder	≥1 hypomanic episode + ≥1 MDD episode; NO full manic episodes; hypomania causes observable change but no marked impairment/hospitalisation	Hypomania: ≥4 consecutive days; MDD: ≥2 weeks
Cyclothymic Disorder	Chronic fluctuating mood with hypomanic and depressive symptoms that do not meet criteria for hypomania or MDD	≥2 years (≥1 year in children/adolescents)

DIGFAST Mnemonic — Manic Episode Criteria

Letter	Symptom
D	Distractibility
I	Impulsivity / Indiscretion (spending, sex, business decisions)
G	Grandiosity (inflated self-esteem, delusional)
A	Activity/energy increase (goal-directed, agitation)
S	Sleep deficit (feels rested after <3 hours)
T	Talkativeness / pressured speech

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Screening for bipolar disorder before prescribing antidepressants: Use the Mood Disorder Questionnaire (MDQ) in any patient presenting with depression. If positive (≥7 "yes" answers in Part 1, "yes" to Part 2, "moderate"/"serious" in Part 3), refer for psychiatric assessment before starting an SSRI. Antidepressant monotherapy in bipolar depression risks inducing mania, mixed states, or rapid cycling.

Pharmacotherapy — Bipolar Disorder

Acute Mania

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Lithium

Lithicarb® · Generic · Mood stabiliser

Adult dose Acute: 250 mg PO TDS (or 450 mg BD SR), titrate to serum level 0.8–1.0 mmol/L. Maintenance: target 0.4–0.8 mmol/L.

Monitoring Serum lithium levels 12-hr post-dose: 5–7 days after initiation, then weekly × 4 weeks, then every 3–6 months when stable. Renal (eGFR, urinalysis), thyroid (TSH), calcium — baseline then every 6 months. ECG at baseline if >50 years or cardiac history.

Renal adjustment Contraindicated if eGFR <30 mL/min; dose reduction required if eGFR 30–60 mL/min. Avoid concurrent NSAIDs, ACE inhibitors, thiazides (reduce lithium clearance).

Hepatic adjustment Not primarily hepatically metabolised; no specific adjustment

Key safety Narrow therapeutic index; toxicity risk with dehydration, diarrhoea, vomiting, renal impairment. Toxic level >1.5 mmol/L. Signs: coarse tremor, confusion, ataxia, seizures, renal failure. Emergency management: supportive, consider haemodialysis if >2.5 mmol/L or severe symptoms.

PBS status ✔ PBS General Benefit

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Sodium Valproate (Divalproex)

Epilim® · Depakote® · Mood stabiliser / anticonvulsant

Adult dose Acute mania: 200 mg PO TDS or 1000–2000 mg/day in divided doses; target trough level 50–100 mg/L (350–700 µmol/L)

Key safety Teratogenic (Category X): CONTRAINDICATED in women of childbearing potential unless enrolled in the Australian Pregnancy Register (valproate causes neural tube defects, neurodevelopmental disorders, reduced IQ). TGA boxed warning.

Renal adjustment No specific adjustment; monitor levels

Hepatic adjustment Contraindicated in severe hepatic impairment; monitor LFTs at baseline, 3 months, 6 months, then annually

PBS status ✔ PBS General Benefit

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Quetiapine

Seroquel® · Atypical antipsychotic

Adult dose Acute mania: 300 mg/day on Day 1, titrate to 600–800 mg/day by Day 4. Bipolar depression: 300 mg/day (monotherapy). Maintenance: 300–600 mg/day.

Key safety Metabolic syndrome (weight gain, dyslipidaemia, hyperglycaemia) — monitor FPG, lipids, waist circumference, BMI every 3 months for first year. Sedation. QTc monitoring if cardiac risk.

PBS status ✔ PBS General Benefit (maintenance); Authority Required (acute mood episodes)

Maintenance / Prophylaxis

Lithium is first-line for maintenance prophylaxis in BD-I (reduces manic and depressive relapse by ~40–50%). Alternatives include lamotrigine (superior for bipolar depression prophylaxis), valproate, and quetiapine. Long-acting injectable antipsychotics (e.g., aripiprazole lauroxil) may be considered for adherence-challenged patients.

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Lamotrigine

Lamictal® · Generic · Anticonvulsant / mood stabiliser

Adult dose Must titrate slowly to avoid Stevens-Johnson syndrome: 25 mg/day × 2 weeks → 50 mg/day × 2 weeks → 100 mg/day × 1 week → 200 mg/day maintenance. If on valproate: start 12.5 mg/day.

Key indication Bipolar depression prophylaxis (most effective mood stabiliser for preventing depressive episodes in BD-II)

Key safety Rash (SJS risk: highest in first 8 weeks, with rapid titration, concomitant valproate, and paediatric patients). Stop immediately if rash develops.

PBS status PBS Authority Required (bipolar maintenance)

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CRITICAL — Bipolar depression ≠ Unipolar depression: Never prescribe antidepressant monotherapy for bipolar depression without a mood stabiliser. If an antidepressant is used in BD-II (controversial), it should always be combined with a mood stabiliser (lithium, lamotrigine, or valproate) and discontinued within 3–6 months of remission. In BD-I, antidepressants are generally avoided due to mania-switch risk.

Perinatal Depression

The perinatal period — from conception to 12 months postpartum — is a time of elevated risk for mood disorders. In Australia, approximately 1 in 7 women (14%) experience perinatal depression, and 1 in 10 experience perinatal anxiety. Paternal perinatal depression affects approximately 1 in 10 new fathers. The condition is associated with adverse maternal, infant, and family outcomes if untreated.

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Terminology distinctions are critical: Postnatal blues (baby blues) is self-limiting; perinatal depression is a clinical disorder requiring treatment; postnatal psychosis is a psychiatric emergency. Accurate differentiation prevents both over-treatment and dangerous under-treatment.

Classification of Perinatal Mood Disorders

Self-Limiting

Postnatal Blues (Baby Blues)

Affects 50–80% of postpartum women
Onset: Day 3–5 postpartum, peaks Day 5, resolves by Day 10–14
Symptoms: mood lability, tearfulness, irritability, anxiety, fatigue
No functional impairment; does not require pharmacological treatment
Management: reassurance, psychoeducation, social support, sleep hygiene, peer support

Setting: GP — reassurance and watchful waiting; no medication indicated

Clinical

Perinatal Depression

Affects ~14% of women during pregnancy or within 12 months postpartum
Risk factors: prior depression, lack of social support, unplanned pregnancy, domestic violence, financial stress, migrant/refugee status, Aboriginal and Torres Strait Islander background, history of childhood adversity
Symptoms: low mood, anhedonia, guilt, fatigue, sleep disturbance beyond what is expected for postpartum, bonding difficulties, intrusive thoughts about harm to infant (ego-dystonic, distinct from psychotic thoughts)
Screening: Edinburgh Postnatal Depression Scale (EPDS) — score ≥13 indicates likely depression; Item 10 screens for suicidal ideation

Setting: GP with perinatal mental health care plan; refer to perinatal mental health services; consider CMHTs; Better Access items apply

Emergency

Postnatal Psychosis (Puerperal Psychosis)

Incidence: 1–2 per 1,000 births; most commonly presents within the first 2 weeks postpartum
Strong association with bipolar disorder (50% have personal or family history of BD); considered a psychiatric emergency
Symptoms: sudden onset confusion, disorientation, paranoia/persecutory delusions, hallucinations (auditory/visual), severe agitation, bizarre behaviour, mood lability, insomnia (marked), disorganised speech, risk of infanticide
Differential: delirium (exclude sepsis — particularly Group A strep endometritis), drug-induced psychosis

Setting: EMERGENCY — call 000 / present to nearest ED. Requires admission, preferably to a Mother–Baby Unit (MBU). Do NOT leave mother alone with infant.

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Postnatal psychosis is a medical emergency. Risk of infanticide and suicide is elevated. The mother should never be left alone with the infant. Call 000, arrange emergency psychiatric assessment, and admission to a Mother–Baby Unit (MBU) where available. MBUs are available in major Australian tertiary centres (e.g., Royal Women's Hospital Melbourne, King Edward Memorial Hospital Perth, Mercy Hospital for Women, Westmead Hospital Sydney).

Edinburgh Postnatal Depression Scale (EPDS)

The EPDS is a 10-item self-report questionnaire validated for use in the Australian perinatal setting. It is recommended by the RANZCP, COPE (Centre of Perinatal Excellence), and the Australian Government that all women be screened using the EPDS at least twice: at the antenatal booking visit (28 weeks) and at the 6-week postnatal check. Additional screening should occur at any time clinical concern arises.

EPDS Score	Interpretation	Action
0–9	Depression unlikely	Reassure; re-screen as clinically indicated
10–12	Possible depression	Clinical interview; monitor closely; offer support services
≥13	Likely depression	Full clinical assessment; safety planning; refer for treatment (psychotherapy ± pharmacotherapy)
Item 10: "self-harm thoughts" — any score >0	⚠️ Suicidal ideation	Immediate risk assessment; safety planning; urgent psychiatric referral if active ideation or plan

Pharmacotherapy in Perinatal Depression

Pharmacotherapy decisions in pregnancy and breastfeeding require careful risk–benefit analysis. Untreated moderate-to-severe depression carries significant risks to both mother and fetus/infant (preterm birth, low birth weight, impaired bonding, adverse child developmental outcomes). In many cases, treatment is safer than non-treatment.

Antidepressants in Pregnancy

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Sertraline

Zoloft® · SSRI — Preferred in pregnancy

Adult dose 50–200 mg PO daily (same as non-pregnant)

Pregnancy safety Category B1 — no evidence of teratogenicity in large cohort studies. Neonatal adaptation syndrome (NAS) possible (jitteriness, irritability, feeding difficulty) — usually self-limiting within 48 hours.

Breastfeeding safety Lowest infant plasma levels of all SSRIs; compatible with breastfeeding. Preferred SSRI for breastfeeding mothers.

PBS status ✔ PBS General Benefit

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Fluoxetine

Prozac® · SSRI

Pregnancy safety Category B3 — extensive human data, generally considered acceptable. Longer half-life (active metabolite) means longer neonatal exposure if NAS occurs. Slightly higher risk of persistent pulmonary hypertension of the newborn (PPHN) with third-trimester exposure (absolute risk very low).

Breastfeeding safety Compatible; moderate infant plasma levels. Long half-life means accumulation over time — monitor infant.

PBS status ✔ PBS General Benefit

Medications to AVOID in Pregnancy and Breastfeeding

Medication	Pregnancy Risk	Breastfeeding Risk
Sodium valproate	Category D — CONTRAINDICATED. Neural tube defects (5–10%), neurodevelopmental disorders, reduced IQ. TGA boxed warning.	Excreted in breast milk; generally avoided
Lithium	Category D — Ebstein's anomaly (cardiac) risk ~0.05–0.1% (lower than previously thought). Use only if benefits clearly outweigh risks, with close monitoring (serum levels, fetal echocardiography at 18–20 weeks).	Excreted in breast milk; monitor infant lithium levels, thyroid, renal function
Paroxetine	Category D — cardiac malformations with first-trimester exposure. Avoid if possible.	Compatible with breastfeeding
Carbamazepine	Category D — neural tube defects (1–2%). Avoid if possible.	Low risk in breast milk
Benzodiazepines (long-acting)	Category C/D — neonatal sedation, floppy infant syndrome, withdrawal. Use short-acting (e.g., lorazepam) only if essential, for the shortest duration possible.	Sedation in infant; avoid if possible
Doxepin	Limited data	CONTRAINDICATED — serious adverse effects reported in breastfed infants

Treatment of Postnatal Psychosis

Immediate: Hospital admission (Mother–Baby Unit preferred); ensure safety of mother and infant; 1:1 nursing supervision
Pharmacotherapy: Atypical antipsychotic (e.g., olanzapine 10–20 mg, quetiapine 300–600 mg) ± benzodiazepine (lorazepam 1–2 mg) for acute agitation; ECT if rapid response needed or catatonic features
Lithium: Initiate early if bipolar aetiology confirmed (monitor serum levels closely in postpartum period — physiological changes affect pharmacokinetics)
Long-term: Risk of recurrence after future pregnancies is ~50%; prophylactic mood stabiliser (lithium) from early in subsequent pregnancy

Australian Perinatal Mental Health Resources

COPE — Centre of Perinatal Excellence

National peak body for perinatal mental health; clinical guidelines, EPDS, screening pathways. Website: cope.org.au

PANDA — Perinatal Anxiety & Depression Australia

National helpline 1300 726 306 (Mon–Fri 9am–7:30pm AEST); online support, referrals, clinical resources

Beyond Blue

1300 22 4636; online counselling; GP resources; perinatal mental health programs

Lifeline

13 11 14 (24/7 crisis support); text 0477 13 11 14

Investigations

Before diagnosing a primary mood disorder, exclude organic causes. The following investigations are recommended at baseline for all patients presenting with a new episode of depression or mood disturbance.

Essential Full blood count (FBC) Exclude anaemia, infection, haematological malignancy. MBS item 66555.

Essential Thyroid function tests (TSH, free T4) Hypothyroidism mimics depression; hyperthyroidism can mimic mania/anxiety. MBS item 66721.

Essential Liver function tests (LFTs) Baseline before antidepressant/mood stabiliser initiation. MBS item 66514.

Essential Renal function (eGFR, creatinine, electrolytes) Essential before lithium initiation. MBS item 66515.

Available Vitamin B12 and folate Deficiency causes mood and cognitive symptoms. MBS item 66841 / 66847.

Available Ferritin and iron studies Iron deficiency contributes to fatigue and mood disturbance. MBS item 66557.

Available Fasting glucose and lipids Metabolic syndrome screening — essential before atypical antipsychotics (quetiapine, olanzapine). MBS item 66527.

Available Urinalysis (urine drug screen) Exclude substance-induced mood disorder. MBS item 69315.

Specialist Lithium serum level monitoring 12-hour post-dose trough. Therapeutic range: acute mania 0.8–1.0 mmol/L; maintenance 0.4–0.8 mmol/L. Toxic >1.5 mmol/L. MBS item 66575.

Specialist Valproate serum level monitoring Trough level: therapeutic range 50–100 mg/L (350–700 µmol/L). MBS item 66575.

Referral ECG Before lithium, high-dose antipsychotics, or TCAs. QTc monitoring for citalopram/escitalopram at higher doses. MBS item 11708.

Referral Brain MRI If organic cause suspected (e.g., first presentation with atypical features, cognitive decline, focal neurological signs). Refer to neurology/psychiatry. MBS item 63001.

Monitoring

Antidepressant Monitoring Schedule

Week 1–2

Telephone or telehealth check: assess tolerability, side effects, suicidal ideation (especially <25 years). Reinforce psychoeducation — therapeutic effect not expected for 2–4 weeks.

Week 2–4

Face-to-face review: assess response (PHQ-9 or K-10), side effects, adherence. If partial response, consider dose optimisation. If no response by week 4, continue to week 6 before switching.

Week 6

Reassess: if adequate response, continue same dose. If inadequate response → dose increase or switch antidepressant class. Refer for psychotherapy if not already engaged.

Week 12

Formal outcome assessment. If remission achieved, continue for ≥6 months (≥12 months if recurrent depression or significant risk factors).

Months 6–12

If stable and in remission, discuss discontinuation plan. Taper antidepressant over 2–4 weeks (4–6 weeks for venlafaxine, paroxetine). Monitor for relapse for 6 months after cessation.

Lithium Monitoring

Parameter	Frequency	Target / Action
Serum lithium level	Day 5–7, then weekly × 4, then 3-monthly when stable	Maintenance 0.4–0.8 mmol/L; acute 0.8–1.0 mmol/L
eGFR, creatinine, electrolytes	Baseline, then 3-monthly for first 12 months, then 6-monthly	Trend eGFR — progressive decline warrants nephrology referral
TSH	Baseline, 6-monthly	Lithium-induced hypothyroidism in ~20% of patients — treat with levothyroxine
Calcium, PTH	Baseline, then annually	Lithium-associated hyperparathyroidism
Weight, BP	Each visit	Lithium may cause weight gain; counsel re: diet and exercise

Monitoring Tools for General Practice

PHQ-9 (Patient Health Questionnaire-9): Validated for severity tracking in Australian primary care; score ≥10 = likely depression; administer at each review
K-10 (Kessler Psychological Distress Scale): Widely used in Australian GP settings; part of the GP Mental Health Treatment Plan assessment
GAD-7: For comorbid anxiety assessment
MDQ (Mood Disorder Questionnaire): Bipolar screening
DAST-10 / AUDIT: Substance use screening (comorbid substance use worsens mood disorder outcomes)

Special Populations

🤰

Pregnancy

Preferred antidepressant: Sertraline (Category B1) or fluoxetine (Category B3)

Avoid: Sodium valproate (Category D — teratogenic), paroxetine (Category D — cardiac defects), benzodiazepines

Bipolar in pregnancy: Discontinuation of mood stabiliser carries 70% relapse risk. Lithium (Category D, but lower Ebstein's risk than historically reported) may be continued with specialist supervision and fetal echocardiography.

Untreated depression carries risks: preterm birth, low birth weight, preeclampsia, impaired bonding. Risk–benefit discussion must be documented.

👶

Paediatrics & Adolescents

MDD ≥8 years: Fluoxetine 10→20 mg/day (first-line, TGA-approved ≥8 years)

MDD ≥13 years: Sertraline 25→50–200 mg/day (TGA-approved for OCD ≥13 years; used off-label for MDD)

Psychotherapy first-line: CBT or IPT-A for mild-to-moderate depression; combined therapy for moderate-to-severe

Bipolar in paediatrics: Refer to child and adolescent psychiatry; quetiapine and lithium have the most evidence in adolescents

TGA boxed warning: increased suicidality risk with SSRIs in <25 years. Close monitoring: weekly for 4 weeks, then fortnightly for 4 weeks. DMDD is the paediatric-specific diagnosis — do NOT diagnose bipolar disorder in prepubertal children with irritability alone.

👴

Elderly (≥65 years)

First-line: Sertraline 25→50–100 mg/day (start low, go slow — half the adult starting dose)

Avoid: TCAs (anticholinergic effects, cardiac toxicity, falls risk); lithium (reduced clearance, narrow therapeutic index); paroxetine (most anticholinergic SSRI)

Cautions: Hyponatraemia (SSRIs, especially in first 2 weeks — check sodium at baseline and 2 weeks); falls risk (benzodiazepines, mirtazapine); serotonin syndrome with tramadol (commonly coprescribed for pain)

Vascular depression is a distinct entity in the elderly — associated with white matter hyperintensities, executive dysfunction, and poor antidepressant response. Late-onset depression (first episode >60 years) warrants cognitive assessment and brain imaging.

🫘

Renal Impairment

Lithium: Contraindicated if eGFR <30 mL/min. Dose reduction if eGFR 30–60 mL/min. Increased monitoring frequency.

SSRIs: Sertraline — no adjustment required. Escitalopram — no adjustment. Fluoxetine — use with caution. Venlafaxine — reduce dose 25–50% if eGFR <30.

Duloxetine: Avoid if eGFR <30 mL/min.

Dialysis patients have high rates of depression (~25–40%). SSRIs are preferred; adjust for dialysis clearance if applicable. Liaison with nephrology.

🫁

Hepatic Impairment

Preferred: Sertraline (reduced dose in severe impairment), escitalopram (max 10 mg/day)

Avoid: Duloxetine (contraindicated in severe hepatic impairment), valproate (hepatotoxicity risk), TCAs (extensive hepatic metabolism)

Monitor: LFTs before initiation and periodically; avoid combination with hepatotoxic agents

Alcohol use disorder commonly co-occurs with hepatic disease and depression — address dual diagnosis; naltrexone may be contraindicated in decompensated liver disease.

🛡️

Immunocompromised

Drug interactions: SSRIs (especially fluoxetine, fluvoxamine) inhibit CYP enzymes — check interactions with antiretrovirals (HIV), tacrolimus/cyclosporine (transplant), chemotherapy agents

HIV: Depression prevalence 2–3× general population. Sertraline and escitalopram preferred (fewest CYP interactions with antiretrovirals)

Transplant: Monitor immunosuppressant levels closely when initiating/changing antidepressants

Fatigue, sleep disturbance, and anhedonia may overlap with disease and treatment effects — careful symptom attribution is required.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health — Mood Disorders

Aboriginal and Torres Strait Islander peoples experience depression and mood disorders at 2–3 times the rate of the non-Indigenous Australian population. Suicide rates among Aboriginal and Torres Strait Islander peoples are approximately twice the national rate, with devastatingly high rates among young people aged 15–24 (approximately 4 times the non-Indigenous rate). Social and emotional wellbeing (SEW) is conceptualised holistically, encompassing connection to land, culture, spirituality, ancestry, community, and family — not merely the absence of mental illness.

⚠️

Cultural considerations in mood assessment: Western psychiatric diagnostic tools (e.g., PHQ-9, K-10) may not capture the experience of mood distress for Aboriginal and Torres Strait Islander peoples. The term "depression" itself may not resonate. "Feeling worried," "feeling shame," "sorry business" (grief), "humbug" (annoyance/stress), and "feeling down" are commonly used expressions. The Westerman Aboriginal Symptoms Checklist (WASC) is a culturally validated screening tool developed by and for Aboriginal and Torres Strait Islander peoples.

Access to specialist care

Remote and very remote communities have severely limited access to psychiatrists and psychologists. Telepsychiatry services (e.g., via the Australian Government's Telehealth MBS items) and fly-in/fly-out (FIFO) mental health clinicians provide some access but are not a substitute for local, culturally safe services. Aboriginal Community Controlled Health Organisations (ACCHOs) are the preferred point of care.

Social determinants

Housing insecurity, overcrowding, incarceration (Aboriginal and Torres Strait Islander peoples are incarcerated at 12.5× the national rate), intergenerational trauma from the Stolen Generations, racism, grief and loss (including frequent community bereavements), and socioeconomic disadvantage are fundamental drivers of mood disorders and must be addressed alongside clinical treatment.

Culturally safe care

Yarning-based approaches to mental health assessment build trust and improve engagement. Trauma-informed care is essential — many Aboriginal and Torres Strait Islander patients have experienced institutional trauma. Involve Aboriginal and Torres Strait Islander health workers (A&TSIHWs) and liaison officers (ATSILOs) in care planning. Gender-concordant practitioners may be preferred for sensitive discussions.

Social and Emotional Wellbeing (SEW) programs

The SEW framework (developed by the Australian Government with Aboriginal and Torres Strait Islander leadership) recognises that wellbeing is inseparable from connection to culture, land, and community. Referral to local ACCHO SEW programs, Healing Foundation services, and culturally specific grief and loss programs is strongly recommended alongside pharmacotherapy.

Medication considerations

In remote communities, medication supply may be intermittent; depot or long-acting formulations may improve adherence for patients who travel frequently. PBS co-payment exemptions apply for Aboriginal and Torres Strait Islander peoples holding a concession card, and Close the Gap PBS Co-payment Program provides free or reduced-cost PBS medicines through ACCHOs and participating pharmacies. Ensure medicines are available through local health services and remote area nurses.

Youth suicide prevention

Aboriginal and Torres Strait Islander youth suicide is a national crisis. Community-led suicide prevention programs (e.g., Yiriman Project, The Healing Foundation's young people's programs) are more effective than top-down clinical interventions. GPS should be familiar with local crisis services and ensure warm referrals — not just a phone number. The 13YARN crisis line (13 92 76) provides 24/7 crisis support by and for Aboriginal and Torres Strait Islander peoples.

📚 References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text rev. Washington, DC: APA; 2022.
2. Australian Bureau of Statistics. National Study of Mental Health and Wellbeing, 2020–2022. ABS Cat. No. 4327.0. Canberra: ABS; 2022.
3. Australian Institute of Health and Welfare. Mental health services in Australia. AIHW; 2023. Available from: https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia
4. National Health and Medical Research Council. Clinical Practice Guidelines for the Management of Depression in Primary Care. Canberra: NHMRC; 2020 (updated).
5. Royal Australian and New Zealand College of Psychiatrists. Australian and New Zealand clinical practice guidelines for the treatment of bipolar disorder. Aust N Z J Psychiatry. 2018;52(11):1035–1070.
6. Centre of Perinatal Excellence (COPE). National Perinatal Mental Health Guideline. Melbourne: COPE; 2023. Available from: https://cope.org.au
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. Malhi GS, Bassett D, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry. 2015;49(12):1087–1206.
9. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework: Mental health. AIHW; 2023.
10. Westerman T. Engagement of Indigenous clients in mental health services: What role do cultural differences play? Adv Ment Health. 2004;3(3):88–98.
11. Australian Government Department of Health and Aged Care. Medicare Benefits Schedule Book — Category 1: Professional Attendances (GP Mental Health Treatment Plan items 2710, 2712). Canberra: Commonwealth of Australia; 2024.
12. Geddes JR, Miklowitz DJ. Treatment of bipolar disorder. Lancet. 2013;381(9878):1672–1682.
13. Therapeutic Goods Administration. Valproate and related medicines — new restrictions for use in women and girls of childbearing potential. TGA Safety Alert; 2023. Canberra: Department of Health and Aged Care.
14. Beyond Blue. Perinatal depression and anxiety: A guide for GPs. Melbourne: Beyond Blue; 2022. Available from: https://www.beyondblue.org.au
15. The Healing Foundation. Working with Aboriginal and Torres Strait Islander people and communities in social and emotional wellbeing. Canberra: The Healing Foundation; 2021.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

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. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
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. 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. 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. 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. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
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. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
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. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
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. 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. 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

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
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. 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. 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. 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. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
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. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
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. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
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. 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. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).