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A clinical assessment of depression may be conducted by a general practitioner or by a psychiatrist or psychologist, who will record the person's current circumstances, biographical history and current symptoms, and a family medical history to see if other family members have suffered from a mood disorder, and discuss the person's alcohol and drug use. A mental state examination includes an assessment of the person's current mood and an exploration of thought content, in particular the presence of themes of hopelessness or pessimism, self-harm or suicide, and an absence of positive thoughts or plans. Specialist mental health services are rare in rural areas, and thus diagnosis and management is largely left to primary care clinicians. This issue is even more marked in developing countries.
Before diagnosing a major depressive disorder, a doctor generally performs a medical examination and selected investigations to rule out other causes of symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism; basic electrolytes and serum calcium to rule out a metabolic disturbance; and a full blood count including ESR to rule out a systemic infection or chronic disease. Testosterone levels may be used to diagnose hypogonadism, a cause of depression in men. Subjective cognitive complaints appear in older depressed people, but they can also be indicative of the onset of a dementing disorder, such as Alzheimer's disease. Depression is also a common initial symptom of dementia. Conducted in older depressed people, screening tests such as the mini-mental state examination, or a more complete neuropsychological evaluation, can rule out cognitive impairment. A CT scan can exclude brain pathology in those with psychotic, rapid-onset or otherwise unusual symptoms. No biological tests confirm major depression. Investigations are not generally repeated for a subsequent episode unless there is a specific medical indication, in which case serum sodium can rule out hyponatremia (low sodium) if the person presents with increased frequency of passing urine, a common side-effect of selective serotonin reuptake inhibitor antidepressants.
DSM-IV-TR and ICD-10 criteria
The most widely used criteria for diagnosing depressive conditions are found in the American Psychiatric Association's revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10) which uses different terminology, calling a similar condition "Recurrent depressive disorder". The latter system is typically used in European countries, while the former is used in the US and many other non-European nations.
Major depressive disorder is classified as a mood disorder in DSM-IV-TR. The diagnosis hinges on the presence of a single or recurrent major depressive episode. Further qualifiers are used to classify both the episode itself and the course of the disorder. The category Depressive disorder not otherwise specified is diagnosed if the depressive episode's manifestation does not meet the criteria for a major depressive episode. The ICD-10 system does not use the term Major depressive disorder, but lists similar criteria for the diagnosis of a depressive episode (mild, moderate or severe); the term recurrent may be added if there have been multiple episodes without mania.
- Depression - Assessment tools
- Depression - Early detection and screening
- Depression - Functional assessment
- Depression - Assessment isssues
- Depression - Evaluation protocols
Psychological therapists tend to have a bias assuming psychological causes and it is important to identify the effects of physical causes of depression and the drugs with side effects of depression which need taking into account, to avoid giving people false hope.
The diagnosis may be applied when an individual meets a sufficient number of the symptomatic criteria for depression as suggested in the DSM-IV-TR or ICD-9/ICD-10. There is an ongoing debate regarding the relative importance of genetic or environmental factors, or gross brain problems versus psychosocial functioning.
According to the DSM-IV-TR criteria for diagnosing a major depressive disorder one of the following two elements must be present (See the DSM cautionary statement.):
- Depressed mood, or
- Loss of interest or pleasure in nearly all activities.
It is sufficient to have either of these symptoms in conjunction with five of a list of other symptoms over a two-week period. These include
- Feelings of overwhelming sadness or fear or the seeming inability to feel emotion (emptiness).
- A decrease in the amount of interest or pleasure in all, or almost all, activities of the day, nearly everyday.
- Changing appetite and marked weight gain or loss.
- Disturbed sleep patterns, such as insomnia, loss of REM sleep, or excessive sleep.
- psychomotor agitation or retardation nearly everyday.
- Fatigue, mental or physical, also loss of energy.
- Feelings of guilt, helplessness, hopelessness, anxiety, or fear.
- Trouble concentrating or making decisions or a generalized slowing and obtunding of cognition, including memory.
- recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Other symptoms sometimes reported but not usually taken into account in diagnosis include
- A decrease in self-esteem.
- Inattention to personal hygiene.
- Sensitivity to noise.
- Physical aches and pains, and the belief these may be signs of serious illness.
- Fear of 'going mad'.
- Change in perception of time.
Depression in children is not as obvious as it is in adults. Here are some symptoms that children might display:
- Loss of appetite.
- Sleep problems, such as recurrent nightmares.
- Learning or memory problems where none existed before.
- Significant behavioral changes; such as withdrawal, social isolation, and aggression.
It is hard for people who have not experienced clinical depression, either personally or by regular exposure to people suffering it, to understand its emotional impact and severity, interpreting it instead as being similar to "having the blues" or "feeling down." As the list of symptoms above indicates, clinical depression is a serious, potentially lethal systemic disorder characterized by interlocking physical, affective, and cognitive symptoms that have consequences for function and survival well beyond sad or painful feelings.
Mnemonics commonly used to remember the DSM-IV criteria are SIGECAPS (sleep, interest (anhedonia), guilt, energy, concentration, appetite, psychomotor, suicidality) and DEAD SWAMP (depressed mood, energy, anhedonia, death (thoughts of), sleep, worthlessness/guilt, appetite, mentation, psychomotor).
Key Texts – Books
Additional material – Books
Key Texts – Papers
Additional material - Papers
- Main article: Clinical depression
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- Dale J, Sorour E, Milner G (2008). Do psychiatrists perform appropriate physical investigations for their patients? A review of current practices in a general psychiatric inpatient and outpatient setting. Journal of Mental Health 17 (3): 293–98.
- Orengo C, Fullerton G, Tan R (2004). Male depression: A review of gender concerns and testosterone therapy. Geriatrics 59 (10): 24–30.
- Reid LM, Maclullich AM (2006). Subjective memory complaints and cognitive impairment in older people. Dementia and geriatric cognitive disorders 22 (5–6): 471–85.
- Katz IR (1998). Diagnosis and treatment of depression in patients with Alzheimer's disease and other dementias. The Journal of clinical psychiatry 59 Suppl 9: 38–44.
- Wright SL, Persad C (December 2007). Distinguishing between depression and dementia in older persons: Neuropsychological and neuropathological correlates. Journal of geriatric psychiatry and neurology 20 (4): 189–98.
- Sadock 2002, p. 108
- Sadock 2002, p. 260
- Palmer B, Gates J, Lader M (2003). Causes and Management of Hyponatremia. The Annals of Pharmacotherapy 37 (11): 1694–702.
- ICD-10:. www.who.int. URL accessed on 2008-11-08.
- Sadock 2002, p. 288
- American Psychiatric Association 2000a, p. 345
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- (2004). Mood (affective) disorders. ICD-10, Chapter V, Mental and behavioural disorders. World Health Organization (WHO). URL accessed on 2008-10-19.
- Carlat DJ. The Psychiatric Review of Symptoms: A Screening Tool for Family Physicians. American Family Physician. Vol. 58/No. 7 (November 1, 1998). Available at: http://www.aafp.org/afp/981101ap/carlat.html. Accessed on: April 30, 2006.
- Depression: major depression criteria. MedicalMnemonics.com. URL: http://www.medicalmnemonics.com/cgi-bin/return_browse.cfm?discipline=Psychiatry&browse=1. Accessed on: April 30, 2006.