Depression Initial Assessment

Clinical Presentation 

It must be important to note that patients may not present with depressive mood and that somatic complaints may predominate. Depression should be suspected in patients who present with physical symptoms (eg fatigue, gastrointestinal [GI] distress or back pain) which cannot be explained or in those who present with pain, anxiety or substance abuse. 

History 

The presence of depressed mood or diminished interest or pleasure in activities (anhedonia), feeling of fatigue or lack of energy (anergia), significant loss of motivation (avolition), changes in appetite or weight, sleep disturbances, and suicidal ideation or behavior are essential in diagnosing depression. 

Diagnosis or Diagnostic Criteria 

Assessment of depression should also include the severity, previous episodes, duration and course of depression, degree of functional impairment and/or disability associated with depression. It is important to determine if other psychiatric or general medical conditions are present.  

Diagnostic evaluation of depression should include the following but not limited to:

• Physical exam
• Mental status exam
• History of past and current illnesses
• History of suicidal thoughts and suicide attempts
• General medical history
• Psychiatric history: Include symptoms of mania because presence of manic symptoms would prompt that the patient be diagnosed with bipolar disorder
• Family history of psychiatric disorders
• Substance abuse history
• Medication review
• Mental status evaluation
• Diagnostic tests as indicated: Screening tools (Patient Health Questionnaire [PHQ9], PHq2 or Two-Question Screen, Beck Depression Inventory for Primary Care)
• Evaluation of functional impairment
• Evaluation of life events and stressors

Clinical specifiers that can be used for treatment decisions include the presence of the following: Anxious distress, catatonic, melancholic, typical, psychotic or mixed features, seasonal pattern, cognitive dysfunction, sleep disturbances or somatic symptoms.

Diagnostic Criteria

• This is based on DSM-5 TR diagnostic criteria. Major depressive disorder is diagnosed when 5 or more of the following symptoms that causes change of distress in previous functioning have been present during the same 2-week period (and at least one of the symptoms is either depressed mood or lack of interest or pleasure):
  • Depressed mood in adults or irritable mood in children that either self-reported or observable most of the day nearly every day
  • Lack or diminished interest or pleasure in almost all activities most of the time, nearly every day
  • Significant weight loss when not dieting, weight gain or appetite disturbance in adults (eg ≥5% change in body weight in a month); while in children, this can be manifested as a failure to attain expected weight gain
  • Sleep disturbance that can be insomnia or hypersomnia nearly daily
  • Psychomotor agitation or retardation
  • Feeling of fatigue or lack of energy nearly every day
  • Sense of diminished/loss of self-worth or inappropriate guilt nearly every day
  • Inability to concentrate and there is indecisiveness
  • Frequent thoughts of death, could be of suicidal attempts, with or without specific plan
• The symptoms cause significant impairment in social, occupational or other areas of functioning
• The symptoms should not be a physiological effect of any substance as well as any general medical condition
• The disorder occurrence is not due to schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders
• Manic and hypomanic episodes have not occurred
• Distinguishing between normal sadness and grief from major depressive disorder is important
  • Bereavement induces great suffering but does not typically induce major depressive disorder
  • When bereavement and major depressive disorder concurrently exist, the latter has more severe symptoms and functional impairment and worse prognosis compared to bereavement alone
  • Diagnosis of major depressive disorder in a patient who had significant loss would need clinical judgement based on the patient’s history and cultural context for expression of grief