Depression
Questionnaire/history:
Screening questions:
- During the last month, have you often been bothered by feeling down, depressed or hopeless?
- During the last month, have you often been bothered by having little interest or pleasure in doing things?
Symptoms of depression present most days, most of the time, for at least 2 weeks:
- Disturbed sleep (decreased or increased compared to usual)?
- Decreased or increased appetite and/or weight?
- Fatigue/loss of energy?
- Agitation or slowing of movements and thoughts?
- Poor concentration of indecisiveness?
- Feelings of worthlessness or excessive or inappropriate guilt?
- Recurrent thoughts of death, recurrent suicidal ideas, or a suicide attempts or specific plan?
At least five defining symptoms during the same two-week period, where at least one of the symptoms is depressed mood or loss of interest or pleasure (DSM-5 definition of depression)?
Thoughts, ideas, plans or intent to self-harm or commit suicide?
Protective factors?
Onset of symptoms?
Duration of symptoms?
Pattern of symptoms?
Severity of symptoms?
- Impact on daily functioning at work?
- Impact on relationship?
- Impact on carer role(s)?
- Safeguarding concerns for children or vulnerable adults in their care?
Recent or past stressful or traumatic life events?
- Difficult interpersonal relationships or relationship breakdown including divorce?
- Job stress or redundancy?
- Debt or financial difficulties?
- Bereavement or other trauma?
- Housing and living conditions?
- Immigration status?
- Social isolation?
Co-existing mental health mental health condition?
- Mood elevation?
- Psychotic symptoms?
- Psychosis?
- Anxiety?
- Post-traumatic stress disorder (PTSD)?
- Eating disorder?
- Learning disability?
- Acquired cognitive impairment (including dementia, traumatic brain injury, Parkinson’s disease)?
Current or previous supportive relationships?
- Partner?
- Other family?
- Friends?
- Carers?
- Statutory or voluntary organisation?
Current lifestyle?
- Diet?
- Physical activity?
- Sleep?
- Alcohol?
- Substance misuse?
Past medical history:
- Depression?
- Episodes of self-harm?
- Domestic violence?
Family history?
- Depression?
- Self-harm/suicide?
Current or previous forensic history?
Current medication?
Previous treatments for depression, symptom response and any adverse effects?
Known drug allergies:
Questionnaires:
PHQ-9 score?
‘Less severe depression’ (PHQ-9 score < 16)?
‘More severe depression’ (PHQ-9 score ≥ 16)?
HADS score?
BDI-II score?
Management:
More severe depression with risk of self-harm or suicide, harm to others, or self-neglect?
Psychotic symptoms?
- Urgent referral to specialist mental health service?
- Referral to crisis resolution and home treatment (CRHT) team needed?
Person carer for a child or vulnerable adult(s) and safe guarding concerns?
- Local safeguarding procedures followed?
New episode of less severe depression and not treatment wanted?
- Offered active monitoring, with the option to consider treatment at any time if needed?
- Ensured person has adequate social support and is aware of sources of help if symptoms worsen?
- Arranged an initial review (within 2-4 weeks), also to follow-up if the person does not attend?
New episode of less severe depression and person wishes to consider treatment?
- Considered offering guided self-help first-line?
- Offered counselling?
- Offered group mindfulness and meditation?
- Offered CBT?
- Offered group exercise?
- Offered SSRI if person wishes to start drug treatment?
- Arranged an initial review (within 2-4 weeks), also to follow-up if the person does not attend?
New episode of more severe depression?
- Offered guided self-help?
- Offered counselling?
- Offered individual CBT?
- Offered individual activation?
- Offered group exercise?
- Offered SSRI or SNRI?
- Arranged an initial review (within 2-4 weeks), also to follow-up if the person does not attend?
- Advised not to drive and to notify the DVLA if significant memory or concentration problems, agitation, behavioural disturbance, or suicidal thoughts?
Ensured adequate social support and awareness of sources to help if symptoms worsen?
Counselled when started antidepressant drug treatments and advised?
Symptoms of anxiety, agitation, hopelessness, or suicidal ideas may increase when starting treatment and when to seek urgent review
Medication usually starts to work within 4 weeks (if the antidepressant is going to work)
Medication may be needed for a least 6 months after the remission of symptoms, to reduce the risk of relapse; people who are at high risk or relapse may need to take medication for longer
Antidepressant drugs are not addictive, but withdrawal symptoms may occur if medication is stopped abruptly, doses are missed, or the full dose is not taken as directed
Antidepressants drugs may affect alertness and concentration, affecting the ability to drive, particularly when starting treatment or after increasing the dose
Review in two weeks after starting antidepressant and subsequent reviews as needed
18-25 years or particular concern for risk of suicide?
Review in one week
Ensured crisis plan identifying potential triggers and strategies to help
Subsequent reviews as needed and within 4 weeks of starting antidepressant treatment
Provided advice on the nature and course of depression, recovery, and sources of information and support including self-help materials, support groups and peer support?
Royal College of Psychiatrists: www.rcpsch.ac.uk: patient informations:
- Cognitive Behavioural Therapy (CBT)
MIND: www.mind.org.uk: patient information: Depression
Depression UK: www.depressionuk.org: patient information: About depression
Mental Health Foundation: www.mentalhealth.org.uk: patient informations: Depression and Cognitive behavioural therapy (CBT)
The Samaritans: www.samaritans.org: telephone helpline: 116 123 (freephone) available 24 hours a day
SANEline: www.sane.org.uk, telephone helpline: 0300 304 7000 open from 4pm to 10pm every day of the year
Resource(s):
NICE CKS: Depression. July 2023