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Recognition and Diagnostics of Depression
Essentials
- Recognize depression behind vague symptoms.
- Diagnose depression by interviewing the patient and assess its severity based on the severity and number of symptoms.
- Assess the patient's current functional and working ability.
- Detect other concurrent syndromes that may require treatment and attention.
General remarks
- 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.
- Rating scales cannot be used to make a diagnosis. Interviewing is necessary to assess the clinical significance of symptoms.
- The functional capacity of a patient with depression may be evaluated by the SOFAS scale (available in DSM-IV).
- The Columbia Suicide Severity Rating Scale (C-SSRS) may be used to assist the evaluation of suicide risk in a patient with depression (http://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/).
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.