Depression in adults: in association with NICE : Page 19

Principles for assessment

When assessing a person who may have depression, conduct a comprehensive assessment that does not rely simply on a symptom count. Take into account both the degree of functional impairment and/or disability associated with the possible depression and the duration of the episode.

In addition to assessing symptoms and associated functional impairment, consider how the following factors may have affected the development, course, and severity of a person's depression:

• Any history of depression and comorbid mental health or physical disorders
• Any past history of mood elevation (to determine if the depression may be part of bipolar disorder)
• Any past experience of, and response to, treatments
• The quality of interpersonal relationships
• Living conditions and social isolation.

Stepped care

The stepped care model provides a framework in which to organise the provision of services, and supports patients, carers, and practitioners in identifying and accessing the most effective interventions. In stepped care the least intrusive, most effective intervention is provided first; if a person does not benefit from the intervention initially offered, or declines an intervention, they should be offered an appropriate intervention from the next step.

Table

Case identification and recognition

You should be alert to possible depression (particularly in people with a past history of depression or a chronic physical health problem with associated functional impairment) and consider asking people who may have depression two questions, specifically:

• 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?

If a person answers yes to either of the depression identification questions, a practitioner who is competent to perform a mental health assessment should review the person's mental state and associated functional, interpersonal, and social difficulties.

When assessing a person with suspected depression, consider using a validated measure (for example, for symptoms, functions, and/or disability) to inform and evaluate treatment.

For people with significant language or communication difficulties, for example people with sensory impairments or a learning disability, consider using the Distress Thermometer and/or asking a family member or carer about the person's symptoms to identify possible depression. If a significant level of distress is identified, investigate further.

The Distress Thermometer is a single item question screen that will identify distress coming from any source. The person places a mark on the scale answering: How distressed have you been during the past week on a scale of 0 to 10? Scores of 4 or more indicate a significant level of distress that should be investigated further.

Low intensity psychosocial interventions

For people with persistent subthreshold depressive symptoms or mild to moderate depression, consider offering one or more of the following interventions, guided by the person's preference:

• Individual guided self help based on the principles of cognitive behavioural therapy
• Computerised cognitive behavioural therapy
• A structured group physical activity programme.

Drug treatment

Do not use antidepressants routinely to treat persistent subthreshold depressive symptoms or mild depression because the risk:benefit ratio is poor, but consider them for people with:

• A past history of moderate or severe depression
• Initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least two years)
• Subthreshold depressive symptoms or mild depression that persists after other interventions.

Treatment for moderate or severe depression

For people with moderate or severe depression, provide a combination of antidepressant medication and a high intensity psychological intervention (CBT or IPT).

Continuation and relapse prevention

Support and encourage a person who has benefited from taking an antidepressant to continue medication for at least six months after remission of an episode of depression. Discuss with the person that:

• This greatly reduces the risk of relapse
• Antidepressants are not associated with addiction.

Review with the person with depression the need for continued antidepressant treatment beyond six months after remission, taking into account:

• The number of previous episodes of depression
• The presence of residual symptoms
• Concurrent physical health problems and psychosocial difficulties.

Psychological interventions for relapse prevention

People with depression who are considered to be at significant risk of relapse (including those who have relapsed despite antidepressant treatment or who are unable or choose not to continue antidepressant treatment) or who have residual symptoms, should be offered one of the following psychological interventions:

• Individual CBT for people who have relapsed despite antidepressant medication and for people with a significant history of depression and residual symptoms despite treatment
• Mindfulness based cognitive therapy for people who are currently well but have experienced three or more previous episodes of depression.

Effective delivery of interventions for depression

All interventions for depression should be delivered by competent practitioners. Psychological and psychosocial interventions should be based on the relevant treatment manuals, which should guide the structure and duration of the intervention. Practitioners should consider using competence frameworks developed from the relevant treatment manuals and for all interventions should:

• Receive regular high quality supervision
• Use routine outcome measures and ensure that the person with depression is involved in reviewing the efficacy of the treatment
• Engage in monitoring and evaluation of treatment adherence and practitioner competence - for example, by using video and audio tapes, and external audit and scrutiny where appropriate.

Depression with anxiety

When depression is accompanied by symptoms of anxiety, the first priority should usually be to treat the depression. When the person has an anxiety disorder and comorbid depression or depressive symptoms, consult the NICE guideline for the relevant anxiety disorder (a BMJ Learning module on anxiety is also available) and consider treating the anxiety disorder first (since effective treatment of the anxiety disorder will often improve the depression or the depressive symptoms).

Assessing depression and its severity

As set out in the introduction, the assessment of depression is based on the criteria in DSM-IV. Assessment should include the number and severity of symptoms, duration of the current episode, and course of illness.

Key symptoms:

• Persistent sadness or low mood
• Marked loss of interest or pleasure.

At least one of these, most days, most of the time for at least two weeks.

If any of above present, ask about associated symptoms:

• Disturbed sleep (decreased or increased compared to usual)
• Decreased or increased appetite and/or weight
• Fatigue or loss of energy
• Agitation or slowing of movements
• Poor concentration or indecisiveness
• Feelings of worthlessness or excessive or inappropriate guilt
• Suicidal thoughts or acts.

Then ask about duration and associated disability, past and family history of mood disorders, and availability of social support

1. Factors that favour general advice and active monitoring:

• Four or fewer of the above symptoms with little associated disability
• Symptoms intermittent, or less than two weeks' duration
• Recent onset with identified stressor
• No past or family history of depression
• Social support available
• Lack of suicidal thoughts.

2. Factors that favour more active treatment in primary care:

• Five or more symptoms with associated disability
• Persistent or long standing symptoms
• Personal or family history of depression
• Low social support
• Occasional suicidal thoughts.

3. Factors that favour referral to mental health professionals:

• Inadequate or incomplete response to two or more interventions
• Recurrent episode within one year
• History suggestive of bipolar disorder
• The person with depression or relatives request referral
• More persistent suicidal thoughts
• Self neglect.

4. Factors that favour urgent referral to specialist mental health services:

• Actively suicidal ideas or plans
• Psychotic symptoms
• Severe agitation accompanying severe symptoms
• Severe self neglect.

Box 1: Depression definitions (taken from DSM-IV)

Subthreshold depressive symptoms: Fewer than five symptoms of depression Mild depression: Few, if any, symptoms in excess of the five required to make the diagnosis and symptoms result in only minor functional impairment Moderate depression: Symptoms or functional impairment are between "mild" and "severe" Severe depression: Most symptoms and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms. Symptoms should be present for at least two weeks and every symptom should be present for most of every day. However, it is doubtful whether the severity of the depressive illness can realistically be captured in a single symptom count. Additional information is always useful. You will need to consider family and previous history as well as the degree of associated disability.