In everyday language the word ‘depression' may mean:
a normal temporary emotional reaction that is often associated with losses and disappointments
depressed mood; this means a prolonged (duration of weeks, months) depressed emotional state, which is one of the main symptoms of depression
actual clinical depressive states that present as syndromes.
In the ICD-10 diagnostic classification, the main types of depression are divided into:
depressive episodes (F32), where the depressive episode is the first the patient has experienced
recurrent depressive disorder (F33), where the patient has had depression at least once before and long-term maintenance treatment needs to be considered.
Examination of a patient with depression
The diagnosis of depression is based on clinical interview.
Valid assessment essentially depends on conducting the examination in an unhurried and safe atmosphere.
During the interview proceed from open questions to more closed ones with the aim of identifying specific symptoms of depression.
Depression is usually triggered by a life change (family relations or work), and identifying the triggering factor will help to analyze the patient's life situation.
The interview should concentrate on:
symptoms and severity of depression
possible psychotic symptoms
other significant mental symptoms
impairment of the capacity to function at work, in family life or in leisure time
thoughts and plans of self-destruction or history of suicide attempts.
Symptoms and diagnosis
The 10 core symptoms of depression according to ICD-10 criteria include
depressed mood
loss of interest and enjoyment
fatigue
reduced self-esteem and self-confidence
unreasonable self-criticism or unwarranted ideas of guilt
recurrent thoughts concerning death or suicide or suicidal behaviour
lack of initiative, feelings of indecision or inability to concentrate
psychomotor slowness or agitation
sleep disorder
change in appetite and weight.
A diagnosis of depression (F32-F33) calls for the simultaneous presence of four of the aforementioned symptoms for a period of at least two weeks; in addition, at least two of the three first-mentioned symptoms must be present. Depression usually lasts several months, taking into account residual symptoms.
The severity of depression according to ICD-10 is assessed by the number of symptoms:
mild: 4 to 5 symptoms
moderate: 6 to 7 symptoms
severe: 8 to 10 symptoms.
Symptom questionnaires or assessment scales can be used to assess the severity of depression. Please note that the definitions of various grades of severity in such questionnaires or scales do not always conform to those in the disease classification.
Other concurrent mental disorders (anxiety or personality disorder, substance abuse) may mask symptoms of depression but are also important to treat as such.
The reasons why depressed patients see a general practitioner, and their willingness and ability to share symptoms of depression may vary greatly.
It is important both to recognize depression behind sleeping problems and fatigue or other individual symptoms and to avoid incorrect overdiagnosis of mild mental symptoms.
Symptom questionnaires and rating scales
Various symptom scales can be used to help to recognize and assess depression.
Severity of symptoms, patient's functional capacity and level of care
States of depression can be divided into categories according to the severity, number and quality of the symptoms.
There is usually a clear but not unambiguous relationship between the severity of depression and the patient's functional and working capacity.
Mild depression
Managed in primary care
Patient is usually capable of work.
Moderate depression
Patient is often not capable of work and cannot cope with routine tasks, and sick leave is usually indicated.
Some patients, i.e. those with severe comorbidities, self-destructive behaviour or prolonged functional incapacity should be referred to specialized psychiatric care.
Severe depression
Patient is in need of continuing frequent surveillance
Managed in specialized psychiatric care
Psychotic depression
In addition to the signs of severe depression, the patient has psychotic symptoms (delusions, hallucinations).
Psychiatric hospital care or very intensive treatment and follow-up in psychiatric out-patient care.
Differential diagnosis
Find out whether the patient has ever experienced extensive elevations of mood, which usually indicates bipolar affective disorder Bipolar Disorder. The Mood Disorder Questionnaire (MDQ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC314375/) may be helpful in considering this. A positive screening result warrants more detailed diagnostic assessment.
Delusions or hallucinations characteristic of schizophrenia indicate a schizoaffective disorder.
An organic mood disorder can be caused by a somatic disease, medication or other chemical substance (e.g. alcohol or drugs of abuse); see Mental Disorders Due to Somatic Disease.
Depression should not be diagnosed if the symptoms are associated with the recent death of a near relative and the clinical picture is consistent with a normal grief reaction.