Step 1: recognition, assessment and initial management
- identifying people with depression
- health professionals 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:
- during the last month, have you often been bothered by:
- feeling down, depressed or hopeless?
- having little interest or pleasure in doing things?
- if the person answers 'yes' to either question
- a practitioner who is competent in mental health assessment should:
- review the person's mental state and associated functional, interpersonal and social difficulties
- consider using a validated measure for symptoms, functions and/or disability
- for people with language or communication difficulties, consider using the Distress Thermometer and/or asking a family member or carer about symptoms; if significant distress is identified
- a practitioner who is not competent in mental health assessment should:
- refer the person to an appropriate professional - if this is not the person's GP, inform the GP
- if the person also has a chronic physical health problem:
- ask three further questions to improve the accuracy of the assessment:
- during the last month, have you often been bothered by:
- feelings of worthlessness?
- poor concentration?
- thoughts of death?
- consider the role of the physical health problem and any prescribed medication in the depression
- check that the optimal treatment for the physical health problem is being provided and adhered to; seek specialist advice if necessary
- assessment and initial management
- for a person who may have depression, conduct a comprehensive assessment that does not rely simply on a symptom count. Take into account:
- the degree of associated functional impairment and/or disability
- the duration of the episode
- health professionals should explore how the following may have affected the development, course and severity of the depression:
- history of depression and comorbid mental health or physical disorders
- any past history of mood elevation
- response to previous treatments
- the quality of interpersonal relationships
- living conditions and social isolation
- if the person has a learning disability or acquired cognitive impairment:
- consider consulting a relevant specialist when developing treatment plans
- where possible, provide the same interventions as for other people with depression; adjust the method of delivery or duration if necessary
- always ask a person with depression directly about suicidal ideation and intent. If there is a risk of self-harm or suicide:
- assess whether they have adequate social support and are aware of sources of help
- arrange help appropriate to the level of risk
- advise them to seek help if the situation deteriorates
Risk assessment and monitoring
- if the person presents considerable immediate risk to themselves or others, refer them urgently to specialist mental health services
- advise the person and their family or carer of the following, and ensure they know how to seek help promptly if required:
- the potential for increased agitation, anxiety and suicidal ideation early in treatment; actively seek out these symptoms and review treatment if they develop marked and/or prolonged agitation
- the need to be vigilant for mood changes, negativity, hopelessness and suicidal ideation, particularly when starting or changing treatment and at times of increased stress
- If the person is assessed to be at risk of suicide, consider:
- take into account toxicity in overdose if an antidepressant is prescribed or the person is taking other medication; if necessary, limit the amount of drug(s) available
- consider increasing the level of support, such as more frequent direct or telephone contacts
- consider referral to specialist mental health services
For more detailed information then consult full guideline (1).
Reference:
- NICE (April 2018). Depression.