Depression

Source:
Clinical Knowledge Summaries - CKS
Publication date:
01 October 2015

Abstract

Depression Last revised in October 2015 Next planned review by December 2018 Summary Back to topDepression: Summary Depression is characterised by persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical, and behavioural symptoms.It is the third most common reason for consultation in general practice in the UK. Each year, about one in twenty adults experience an episode of depression.The average length of a depressive episode is 6–8 months. The risk of recurrence is:At least 50% after a first episode of depression, 70% after a second episode and 90% after a third episode.Increased in people under 20 years of age, and in elderly people.Depression is diagnosed according to the DSM-5 classification by the presence of at least five out of a possible nine defining symptoms, present for at least 2 weeks, of sufficient severity to cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.People with depression should be assessed and managed for:The risk of suicide.Any safeguarding concerns for children or vulnerable adults in their care.Co-morbid conditions associated with depression.For people with mild-to-moderate depression, low-intensity psychological interventions (such as individual guided self-help, computerized cognitive behavioural therapy (CBT) or a structured group-based physical activity programme) are recommended.Antidepressants are not used routinely for mild-to-moderate depression, but may be used for people with a history of depression, persistent subthreshold symptoms, or a concomitant chronic physical health problem.For people with moderate or severe depression, a combination of an antidepressant and a high-intensity psychological intervention (such as CBT or interpersonal therapy) is recommended.For a first episode of depression, a generic selective serotonin reuptake inhibitor such as citalopram, fluoxetine, paroxetine, or sertraline is recommended.For a recurrent episode, an antidepressant that has previously elicited a good response may be more appropriate.Frequent, regular review should be arranged for all people with depression to assess:Suicide risk.Safeguarding concerns.Response to treatment.Adherence to treatment and adverse effects.Antidepressants should be continued for at least 6 months following remission of symptoms, as this greatly reduces the risk of relapse. Have I got the right topic? Back to topHave I got the right topic? From age 18 years onwards.This CKS topic is based on guidelines published by the National Institute for Health and Care Excellence (NICE) — Depression: the treatment and management of depression in adults (CG90) [National Collaborating Centre for Mental Health, 2009a] and Depression in adults with a chronic physical health problem (CG91) [National Collaborating Centre for Mental Health, 2009b].This CKS topic covers the assessment and management of adults with depression in primary care.This CKS topic does not cover the management of pregnant or breastfeeding women with depression, or people with other primary psychiatric disorders such as schizophrenia.There are separate CKS topics on Bipolar disorder, Depression - antenatal and postnatal, Poisoning or overdose, and Psychosis and schizophrenia.The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care. How up-to-date is this topic? Back to topHow up-to-date is this topic? Back to top Changes Changes October 2015 — minor update. Based on an update to the manufacturer's Summary of Product Characteristics (SPC). Gynaecological haemorrhage and severe and potentially fatal allergic reactions (very rare) have been included as possible adverse effects of paroxetine.The Drug interaction section has been updated to include the possible interaction between selective serotonin reuptake inhibitors (SSRIs) and pravastatin.July 2015 — minor update. Based on an update to the manufacturer's SPC, severe hepatic disorders (with potential fatal outcome) have been included as possible adverse effects of trazodone.March 2015 — minor update. Addition of rhabdomyolysis and urinary retention as adverse effects of mirtazapine.October 2014 — minor update. Addition of constipation as a common adverse effect of mirtazapine.April 2014 — minor update. Update to the link for the BDI depression questionnaire.December 2013 — minor update. Text in management rewritten to clarify that antidepressants should be continued for at least 6 months following remission of symptoms. Typographical errors also corrected.July to August 2013 — reviewed. Literature searches were conducted in July 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The structure of this topic has been changed to improve clarity; however, there are no changes to the recommendations. Back to top Previous changes Previous changes March 2011 — minor update. The NICE quality standards on the management of depression have been added. Issued in June 2011.December 2010 — minor update. Expert opinion from UK Medicines Information (UKMI) on the choice of antidepressant in people with epilepsy has been added to the Prescribing information section on Chronic physical health problems. Issued in December 2010.October 2010 — minor update. Information on fitness to drive from the Driver and Vehicle Licensing Agency's guidance for medical practitioners, At a glance guide to the current medical standards of fitness to drive has been added. Issued in October 2010.June 2010 — minor update. The Medicines and Healthcare products Regulatory Agency (MHRA) has advised that epidemiological data show that SSRIs and TCAs are associated with a small increased risk of fractures. However, the mechanism leading to this increased risk is unclear. Issued in June 2010.March 2010 — minor update to correct a typographical error in the prescribing information text. Issued in March 2010.August 2009 to February 2010 — reviewed. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.March 2009 — minor update. The Quality and Outcomes Framework (QOF) indicators for depression have been updated in the Goals and outcome measures section. Hypopituitarism following traumatic brain injury has also been included as an underlying cause of depression. Issued in April 2009.September 2008 — minor correction to the Changes section. Issued in September 2008.November 2007 — updated to include recommendations from NICE technology appraisal Computerised cognitive behavioural therapy for depression and anxiety.June 2006 — updated to include amended NICE guidance regarding venlafaxine.January 2006 — updated to include recent advice from the MHRA regarding the safety of paroxetine in pregnancy. Quality and outcomes framework indicators for depression included. Issued in February 2006.May 2005 — rewritten. Validated in September 2005 and issued in November 2005.April 2004 — updated to include recent advice from the Committee on Safety of Medicines that the recommended target dosage of paroxetine is 20mg daily. Maintenance prescriptions for higher doses have been removed. Issued in July 2004.November 2002 — updated to include the management of postnatal depression. Validated in March 2003 and issued in April 2003.September 2001 — reviewed. Validated in November 2001 and issued in April 2002. This guidance will be rewritten when the National Institute for Health and Care Excellence (NICE) publishes its guidance on the primary care management of depression, which is anticipated in September 2003.August 1998 — written, replacing the guidance Single major depressive episode and Recurrent major depressive episode. Back to top Update Update Back to top New evidence New evidence Evidence-based guidelinesGuidelines published since the last revision of this topic:NICE (2017) Antenatal and postnatal mental health: clinical management and service guidance (update). National Institute for Health and Care Excellence. www.nice.org.uk. [Free Full-text]Cleare, A., Pariante, C.M., Young, A.H., et al. (2015) Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines. Journal of psychopharmacology29(5), 459-525. [Abstract]MQIC (2014) Primary care diagnosis and management of adults with depression. Michigan Quality Improvement Consortium www.mqic.org. [Free Full-text]NIHR (2018) The most effective antidepressants for adults revealed in major review. National Institute for Health Research. www.nihr.ac.uk [Free Full-text]Department of Health and Social Care (2019) Suicide prevention: fourth annual report. Department of Health and Social Care. www.gov.uk [Free Full-text]HTAs (Health Technology Assessments)No new HTAs since 1 July 2013.Economic AppraisalsNo new economic appraisals relevant to England since 1 July 2013.Systematic reviews and meta-analysesBarnard, K., Peveler, R.C. and Holt, R.I. (2013) Antidepressant medication as a risk factor for type 2 diabetes and impaired glucose regulation: systematic review. Diabetes Care 36(10), 3337-3345. [Abstract].Churchill, R., Moore, T.H.M., Furukawa, T.A., et al. (2013) 'Third wave' cognitive and behavioural therapies versus treatment as usual for depression (Cochrane Review). The Cochrane Library. Issue 10. John Wiley & Sons, Ltd. www.thecochranelibrary.comCuijpers, P., Sijbrandij, M., Koole, S.L., et al. (2014) Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. World Psychiatry 13(1), 56-67. [Abstract] [Free Full-text].Guaiana, G., Gupta, S., Chiodo, D., et al. (2013) Agomelatine versus other antidepressive agents for major depression (Cochrane Review). The Cochrane Library. Issue 12. John Wiley & Sons, Ltd. www.thecochranelibrary.comHunot, V., Moore, T.H.M., Caldwell, D.M., et al. (2013) 'Third wave' cognitive and behavioural therapies versus other psychological therapies for depression (Cochrane Review). The Cochrane Library. Issue 10. John Wiley & Sons, Ltd. www.thecochranelibrary.comKeyes, K.M., Chesleck-Postava, K., Westhoff, C., et al. (2013) Association of hormonal contraceptive use with reduced levels of depressive symptoms: a national study of sexually active women in the United States. American Journal of Epidemiology 178(9), 1378-1388. [Abstract].Kohler, O., Benros, M. E., Nordentoft, M., et al. (2014) Effect of anti-inflammatory treatment on depression, depressive symptoms, and adverse effects: a systematic review and meta-analysis of randomized clinical trials. JAMA Psychiatry 71(12), 1381-1291. [Abstract] [Free Full-text].Li, G., Mbuagbaw, L., Samaan, Z., Falavigna, M., et al. (2013) Efficacy or vitamin D supplementation in depression in adults: a systematic review. Journal of Clinical Endocrinology and Metabolism 99(3), 757-767.  [Abstract].Linde, K., Sigterman, K., Kriston, L, et al. (2015) Effectiveness of psychological treatments for depressive disorders in primary care: systematic review and meta-analysis. Annals of Family Medicine 13(1), 56-68 [Abstract] [Free Full-text].Maneeton, N., Maneeton, B., Eurvitiyanukul, L., and Srisurapanont, M. (2013) Efficacy, tolerability, and acceptability of bupropion for major depressive disorder: a meta-analysis of randomized-controlled trials comparison with venlafaxine. Drug Design, Development and Therapy 7, 1053-1062. [Abstract].Purgato, M., Papola, D., Gastaldon, C., et al. (2014) Paroxetine versus other anti-depressive agents for depression (Cochrane Review). The Cochrane Library. Issue 4. John Wiley & Sons, Ltd. www.thecochranelibrary.comReichenpfader, U., Gartlehner, G., Morgan, L.C., et al. (2014) Sexual dysfunction associated with second-generation antidepressants in patients with major depressive disorder: results from a systematic review with network meta-analysis. Drug Safety 37(1), 19-31. [Abstract].Shaffer, J.A., Edmondson, D., Wasson, L.T., et al. (2014) Vitamin D supplementation for depressive symptoms: a systematic review and meta-analysis of randomized controlled trials. Psychosomatic Medicine epub ahead of print. [Abstract].Shinohara, K., Honyashiki, M., Imai, H. et al. (2013) Behavioural therapies versus others psychological therapies for depression (Cochrane Review). The Cochrane Library. Issue 10. John Wiley & Sons, Ltd. www.thecochranelibrary.comTaylor, D., Sparshatt, A., Varma, A. and Olofinjana, O. (2014) Antidepressant efficacy of agomelatine: meta-analysis of published and unpublished trials. BMJ 348, g1888. [Abstract] [Free Full-text].Turner, P., Kantaria, R., and Young, A.H. (2014) A systematic review and meta-analysis of the evidence base for add-on treatment for patients with major depressive disorder who have no responded to antidepressant treatment: a European perspective. Journal of Psychopharmacology 28(2), 85-98. [Abstract].Wang, F., Lee, E.K., Wu, T., et al. (2013) The effects of Tai Chi on depression, anxiety, and psychological well-being: a systematic review and meta-analysis. International Journal of Behavioral Medicine epub ahead of print. [Abstract].Wiles, N., Thomas, L., Abel, A., et al. (2014) Clinical effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: the CoBalT randomised controlled trial. Health Technology Assessment 18(31). [Abstract] [Free Full-text].McLachlan, G. (2018) Treatment resistant depression: what are the options? British Medical Journal. www.bmj.com [Free Full-text]Horowitz, M., and Taylor, D. (2019) Tapering of SSRI treatment to mitigate withdrawal symptoms. The Lancet Psychiatry. www.thelancet.com [Free Full-text]Primary evidenceMacpherson, H., Richmond, S., Bland, M., et al. (2013) Acupuncture and counselling for depression in primary care: a randomised controlled trial. PLoS Medicine 10(9), e1001518. [Abstract] [Free Full-text].Richards, D.A., Hill, J.J., Gask. L., et al. (2013) Clinical effectiveness of collaborative care for depression in UK primary care (CADET): cluster randomised controlled trial. BMJ 347, f4913. [Abstract] [Free Full-text].Kohler, O., Benros, M. E., Nordentoft, M., et al. (2014) Effect of anti-inflammatory treatment on depression, depressive symptoms, and adverse effects: a systematic review and meta-analysis of randomised clinical trials. JAMA Psychiatry 71(12), 1381-1391 [Abstract]. Back to top New policies New policies No new national policies or guidelines since 1 July 2013. Back to top New safety alerts New safety alerts No new safety alerts since 1 July 2013. Back to top Changes in product availability Changes in product availability No changes in product availability since 1 July 2013. Goals and outcome measures Back to topGoals and outcome measures Back to top Goals Goals To support primary healthcare professionals to:Identify people with depression.Restore health and function through the complete relief of symptoms.Treat depression effectively (to improve mood, social and occupational functioning, and quality of life).Reduce the chance of relapse or recurrence.Reduce morbidity and mortality from attempted suicide.Minimize adverse effects of treatment. Back to top Outcome measures Outcome measures No outcome measures were found during the review of this topic. Back to top Audit criteria Audit criteria The guidelines published by the National Institute for Health and Care Excellence (NICE), Depression: the treatment and management of depression in adults (CG90) [National Collaborating Centre for Mental Health, 2009a] and Depression in adults with a chronic physical health problem (CG91) [NICE, 2009a], do not advise on specific audit criteria. Back to top QOF indicators QOF indicators Table 1. Indicators related to depression in the Quality and Outcomes Framework (QOF) of the General Medical Services (GMS) contract.IndicatorPointsPayment stagesDepressionDEP001 The percentage of patients aged 18 or over with a new diagnosis of depression in the preceeding 1 April to 31 March who have had a bio-phsychosocial assessment by the point of diagnosis. The completion of the assessment is to be recorded on the same day as the diagnosis is recorded.1750-90%DEP002 The percentage of patients aged 18 or over with a new diagnosis of depression in the preceeding 1 April to 31 March who have been reviewed not earlier than 10 days and not later than 35 days after the date of diagnosis.845-80%Data from: [BMA and NHS Employers, 2013] Back to top QIPP - Options for local implementation QIPP - Options for local implementation First-choice antidepressant use in adults with depression or generalised anxiety disorder:Review and, where appropriate, revise prescribing of antidepressants in adults to ensure that it is line with NICE guidance.[NICE, 2013] Back to top NICE quality standards NICE quality standards People who may have depression receive an assessment that identifies the severity of symptoms, the degree of associated functional impairment and the duration of the episode.Practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression receive regular supervision that ensures they are competent in delivering interventions of appropriate content and duration in accordance with NICE guidance.Practitioners delivering pharmacological, psychological or psychosocial interventions for people with depression record health outcomes at each appointment and use the findings to adjust delivery of interventions.People with persistent subthreshold depressive symptoms or mild to moderate depression receive appropriate low-intensity psychosocial interventions.People with persistent subthreshold depressive symptoms or mild depression are prescribed antidepressants only when they meet specific clinical criteria in accordance with NICE guidance.People with moderate or severe depression (and no existing chronic physical health problem) receive a combination of antidepressant medication and either high-intensity cognitive behavioural therapy or interpersonal therapy.People with moderate depression and a chronic physical health problem receive an appropriate high-intensity psychological intervention.People with severe depression and a chronic physical health problem receive a combination of antidepressant medication and individual cognitive behavioural therapy.People with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions, receive collaborative care.People with depression who benefit from treatment with antidepressants are advised to continue with treatment for at least 6 months after remission, extending to at least 2 years for people at risk of relapse.People with depression whose treatment consists solely of antidepressants are regularly reassessed at intervals of at least 2 to 4 weeks for at least the first 3 months of treatment.People with depression that has not responded adequately to initial treatment within 6 to 8 weeks have their treatment plan reviewed.People who have been treated for depression who have residual symptoms or are considered to be at significant risk of relapse receive appropriate psychological interventions.[NICE, 2011] Background information Back to topBackground information Back to top Definition What is it? Depression is characterised by persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical, and behavioural symptoms.It is defined in the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the presence of at least five out of a possible nine defining symptoms, present for at least 2 weeks, of sufficient severity to cause clinically significant distress or impairment in social, occupational, or other important areas of functioning [American Psychiatric Association, 2013].Subthreshold depressive symptoms describe a situation when an individual has some of the 9 defining symptoms of depression but they are insufficient in number or severity to meet the full criteria to diagnose depression [National Collaborating Centre for Mental Health, 2009a].Persistent subthreshold depressive symptoms are defined by the National Institute of Health and Clinical Excellence as persistence of subthreshold depressive symptoms for more than 2 years. This has previously been referred to as dysthymia [National Collaborating Centre for Mental Health, 2009a]. Back to top Prevalence How common is it? Depression is the third most common reason for consultation in general practice in the UK [National Collaborating Centre for Mental Health, 2009a].Each year, about one in twenty adults experience an episode of depression.An episode of depression serious enough to require treatment occurs in about one in four women and one in ten men at some point in their lives.Approximately one in four people with two or more chronic health problems are depressed compared to only 3% of people who are physically healthy [Moussavi et al, 2007].Subthreshold depressive symptoms lasting for at least 2 years will be experienced by an estimated 2.5–5% of people at some point during their lives [Waraich, 2004]. Back to top Risk factors What are the risk factors for depression? The cause of depression is unknown but is likely to result from a complex interaction of biological, psychological, and social factors. Factors that may increase the risk of depression include [National Collaborating Centre for Mental Health, 2009a]:Psychosocial issues such as unemployment, divorce, and poverty.Genetic factors.Personality.Failure of adaptive mechanisms to stressors.Chronic comorbidities such as diabetes, chronic obstructive pulmonary disease, cardiovascular disease and especially people with chronic pain syndromes.A past head injury, including hypopituitarism following trauma [Bavisetty et al, 2008; Wasserman et al, 2008]. Back to top People at high risk of depression Who is at high risk of depression? People who are at high-risk of depression include anyone with [National Collaborating Centre for Mental Health, 2009a; National Collaborating Centre for Mental Health, 2009b]:A history of depression, suicide attempt, or any form of abuse (sexual, physical, or substance).Significant physical illness (such as coronary heart disease, chronic pain syndrome).Other mental health problems, such as schizophrenia and dementia.A family history of depression.Frequent visits to the GP or emergency department.The National Institute for Health and Care Excellence (NICE) recommend screening for depression in people who are at high risk.Ask about the two 'core' symptoms of depression.During the last month have you often been bothered by feeling down, depressed, or hopeless?Do you have little interest or pleasure in doing things?A 'yes' response to one of the two questions has high specificity for depression (0.95, 95% CI 0.91 to 0.97) but low sensitivity (0.66, 95% CI 0.55 to 0.76) [National Collaborating Centre for Mental Health, 2009a].If they answer yes to either or both of these questions, undertake a full assessment for depression. For more information, see Diagnosis.[National Collaborating Centre for Mental Health, 2009a; National Collaborating Centre for Mental Health, 2009b] Back to top Complications What are the complications? Depression:Exacerbates the pain, disability, and distress associated with a range of physical diseases [Cassano, 2002].Increases mortality:In a range of comorbid conditions [Cassano, 2002] including coronary heart disease [Nicholson et al, 2006].From suicide.Suicide in people who are depressed accounts for nearly 0.6% of all deaths in the general population [Sartorius, 2001].There is a four-times higher risk of suicide in depressed people compared with the general population (2.2% compared with less than 0.5%), and the risk of suicide is nearly 20-times higher in the most severely ill [Bostwick, 2000].Impairs a person's ability to function normally, which may result in:Employment problems.Neglect of dependants [Ramchandani and Stein, 2003].Family problems and relationship break-ups.Increases the risk of substance abuse.[National Collaborating Centre for Mental Health, 2009a; SIGN, 2010] Back to top Prognosis What is the prognosis? The average length of an episode of depression is 6–8 months. The prognosis is worse for people with [American Psychiatric Association, 2013]:Psychotic features.Prominent anxiety.Personality disorders.Severe symptoms.The risk of recurrence is:At least 50% after a first episode of depression, 70% after a second episode and 90% after a third episode [Kupfer, 1991].Increased in people less than 20 years of age, and in elderly people.Persistent depression develops in at least 10% of people with depression [Kessler, 2003].Persistent subthreshold depressive symptoms progresses to the full criteria for depression in about 70% of people [Waraich, 2004].[National Collaborating Centre for Mental Health, 2009a] Diagnosis Back to topDiagnosis Back to top Diagnosis How do I diagnose depression? Depression is diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria.Assess for the two 'core' symptoms of depression by asking:During the last month have you often been bothered by feeling down, depressed, or hopeless?Do you have little interest or pleasure in doing things?If either of the two 'core' symptoms have been present most days, most of the time, for at least 2 weeks, ask about:Other typical symptoms of depression:Fatigue/loss of energy.Worthlessness/excessive or inappropriate guilt.Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts.Diminished ability to think/concentrate or indecisiveness.Psychomotor agitation or retardation.Insomnia/hypersomnia.Significant appetite and/or weight loss.Symptoms of atypical depression. These include reactive mood, increased appetite, weight gain, excessive sleepiness and sensitivity to rejection.A symptom is counted as significant if it is sufficiently severe and/or persistent to be causing significant distress or functional impairment.Depression is diagnosed if the person has at least five out of the nine symptoms listed above, with at least one of these a 'core' symptom.'Subthreshold depressive symptoms' is diagnosed if the person has at least two, but less than five, symptoms that are required for the diagnosis of depression. They are usually able to cope with everyday life.'Persistent subthreshold depressive symptoms' (sometimes termed dysthymia) is diagnosed if the person:Has at least 2 years of depressed mood for more days than not, which is not the consequence of a partially resolved 'major' depression, andHas at least two, but less than five of the symptoms that are required for the diagnosis of depression.Seasonal affective disorder is diagnosed if the person has episodes of depression which recur annually at the same time each year with remission in between (usually appearing in winter and remitting in spring).Investigations are not routinely indicated for people with depression, but may be necessary to exclude other causes for symptoms or conditions known to be associated with depression (see Differential diagnosis). Basic laboratory tests that may be indicated include:Biochemistry: blood glucose, urea and electrolytes, creatinine, liver function tests, thyroid function tests, calcium levels.Haematology: full blood count and erythrocyte sedimentation rate. Back to top Basis for recommendation Basis for recommendation These recommendations are based on guidelines published by the National Institute for Health and Care Excellence (NICE) — Depression: the treatment and management of depression in adults National Collaborating Centre for Mental Health, 2009 NICE, 2009, Depression in adults with a chronic physical health problem National Collaborating Centre for Mental Health, 2009 NICE, 2009, and Common mental health disorders National Collaborating Centre for Mental Health, 2011.Choice of diagnostic criteria to confirm the diagnosis of depressionDepression is usually confirmed by one of two main classification systems: the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) American Psychiatric Association, 2013 or the tenth revision of the International Classification of Diseases (ICD-10) WHO, 1992.The 2009 NICE guideline NICE, 2009 adopted the DSM-IV criteria in preference to ICD-10 criteria previously used in the 2004 guideline. NICE preferred DSM-IV because the evidence base for treatments refers, to a larger extent, to these criteria. Subsequent to the publication of this NICE guidance, DSM-IV American Psychiatric Association, 2000 has been replaced with DSM-5 American Psychiatric Association, 2013; however core criteria for diagnosing depression have not changed.Subthreshold depressive symptoms and persistent subthreshold depressive symptoms (dysthymia)Dysthymia appears as a category in both DSM-5 and ICD-10, acknowledging that subthreshold symptoms may become chronic and may require treatment, even if fairly mild. NICE recommends the term 'persistent subthreshold depressive symptoms' over dysthymia.Depression with a seasonal patternNICE accepts the usefulness of the term depression with a seasonal pattern, and major depression with a seasonal pattern is also recognized in DSM-5 American Psychiatric Association, 2013. However opinions in Europe differ on whether this is a distinct condition or a trait that appears anyway in those with or without depression National Collaborating Centre for Mental Health, 2009. Depression with atypical featuresNICE also accepts the usefulness of the term depression with atypical features National Collaborating Centre for Mental Health, 2009, and this is also recognized by DSM-5 American Psychiatric Association, 2013.Investigations for people with depressionNICE makes no specific recommendations regarding laboratory tests for depression National Collaborating Centre for Mental Health, 2009.The investigations outlined are those recommended in a handbook on laboratory investigation of people with psychiatric disorders Foster, 2008. Back to top Differential diagnosis What is the differential diagnosis? Grief reaction — it may be difficult to distinguish normal grief from depressive illness. Uncomplicated bereavement and major depression share many symptoms, but active suicidal thoughts, psychotic symptoms, and profound guilt are rare with normal bereavement. Table 1 compares the different characteristics of grief and depression.Table 1. Depression and grief compared.Characteristics of griefCharacteristics of depressionBiological symptoms of loss of sleep, appetite, and concentrationBiological symptoms plus psychological symptoms of hopelessness, worthlessness, and guiltDistress relates to a particular lossDistress is usually generalized to all facets of lifThe person retains the capacity for pleasureThe person enjoys nothingGrief comes in wavesDepression is constant and unremittingThe person may express a passive wish for life to endThe person may express suicidal ideationThe person is able to look forward to the futureThe person has no sense of a positive futureMost people cope without medical interventionMedical or psychological intervention is usually necessaryData from: [Widera and Block, 2012]Dementia may present as depression and vice versa.Approximately a third of people with dementia develop depressive symptoms, and distinguishing depression from dementia can be difficult, as they share symptomatology (disorientation, memory loss, and distractability). A primary diagnosis of depression is suggested by:Preservation of a reasonable memory.Personal or family history of depression.A successful trial of treatment for depression which alleviates dementing symptoms.For more information, see the CKS topic on Dementia.Substances and adverse drug effects may produces depressive symptoms.Carbon monoxide poisoning can present with irregularities of the mental state (see the CKS topic on Carbon monoxide poisoning.Substance misuse (for example alcohol, anabolic steroids, cannabis, cocaine, narcotics) is frequently associated with symptoms of depression.Drug adverse effects are an uncommon cause of depression. Examples include centrally-acting antihypertensives (such as methyldopa), lipid-soluble beta-blockers (such as propranolol), central nervous system depressants, opioid analgesics, and isotretinoin.Hypothyroidism may present as depression. For more information, see the CKS topic on Hypothyroidism. Back to top Basis for recommendation Basis for recommendation This information regarding the differential diagnosis for depression is taken from the text book Clinical laboratory investigation and psychiatry: a practical handbook [Foster, 2008], and a review article [Agha, 2006].Distinguishing grief from depressionThis information is taken from expert opinion in a review article of three case reports of people who were terminally ill [Widera and Block, 2012]. Management Back to topManagement Scenario: New or initial management: covers the initial management of a person with depression.Scenario: Ongoing management: covers management of the review period, use of different interventions, the available and recommended treatment strategies, and how to minimize the risk of relapse. Back to top Scenario: New or initial management Scenario: New or initial management From age 18 years onwards. Back to top Assessment How should I assess someone with depression? A record of a bio-psychosocial assessment of people with depression is required by the Quality and Outcomes Framework (QOF). This should be completed on the same day the diagnosis of depression is recorded in the patient record. This includes assessment for:The risk of suicide.Any safeguarding concerns for children or vulnerable adults in the care of someone with depression. Follow local safeguarding procedures if appropriate.Co-morbid conditions associated with depression including:Alcohol or substance abuse — for more information, see the CKS topic on Alcohol - problem drinking.Anxiety — for more information, see Detection in the CKS topic on Generalized anxiety disorder.Eating disorders — for more information, see the CKS topic on Eating disorders.Psychotic symptoms — for more information, see the CKS topics on Psychosis and schizophrenia and Bipolar disorder.Dementia — for more information, see the CKS topic on Dementia.The severity of depression is based on:The number, duration, and severity of symptoms, and their impact socially and functionally. The severity of depression is classified as:Subthreshold depression — less than the five symptoms required to make a diagnosis of major depression.Mild depression — few, if any, symptoms in excess of the five required to make the diagnosis, and only minor functional impairment.Moderate depression — symptoms or functional impairment between mild and severe. Some symptoms would be expected to be marked.Severe depression — several symptoms in excess of those required to make the diagnosis. Some symptoms would be expected to be severe and markedly interfere with functioning.A depression questionnaire. This may be used as well to give an indication of the severity of depression and to help assess improvement over time.Stresses contributing to the development of depression such as:Employment or financial worries.Poor living conditions.Problems with interpersonal relationships (for example partner, children, or parents).Bereavement. Uncomplicated bereavement and major depression share many symptoms, but active suicidal thoughts, psychotic symptoms, and profound guilt are rare with normal bereavement.For more information, see the section on grief reaction in Differential diagnosis.A personal and family history of depression.Sources of support that might be available to the person, such as friends, family, bereavement councillors, and health visitors.Past experience of, and response to, treatment. Back to top Assessing risk of suicide How do I assess the risk of suicide? Directly ask about suicidal thoughts and intent. Do not avoid the word 'suicide'.Ask:Do you ever feel that life is hopeless and not worth living?Do you ever think about suicide?Have you made any plans for ending your life?Do you have the means for doing this available to you?What has kept you from acting on these thoughts?Follow up on 'not really' answers.Identify risk factors that increase the risk of suicide (see Table 1), particularly previous attempts at suicide or self-harm, or a feeling of hopelessness.Assess adequacy of social support and current personal circumstances.Identify factors that reduce the risk of suicide, including good social support and responsibility for children.Table 1. Risk factors for suicide.Social characteristicsHistoryClinical/diagnostic featuresMale genderPrior suicide attempt(s)HopelessnessYoung age ( 18 years), with additional searches in the following areas:BereavementManagement of substance misuse in depressionThe search excluded depression in pregnant women and women with postnatal depression, children and adolescents.Search datesOctober 2009 - July 2013Key search termsVarious combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.exp Depression/, exp Depressive Disorder/, exp Dysthymic Disorder/, exp Seasonal Affective Disorder/, depress$.tw., depressive disorder.tw., dysthymic disorder.tw., seasonal affective disorder.tw.exp Bereavement/, bereave$.tw., exp Grief/, grief.tw., grieving.tw.substance$.tw., drug$.tw., alcohol.tw., drink$.tw., abus$.tw., misuse.tw.Sources of guidelines National Institute for Health and Care Excellence (NICE) Scottish Intercollegiate Guidelines Network (SIGN) Royal College of Physicians Royal College of General Practitioners Royal College of Nursing NICE Evidence Health Protection Agency World Health Organization National Guidelines Clearinghouse Guidelines International Network TRIP database GAIN NHS Scotland National Patient Pathways New Zealand Guidelines Group Agency for Healthcare Research and Quality Institute for Clinical Systems Improvement National Health and Medical Research Council (Australia) Royal Australian College of General Practitioners British Columbia Medical Association Canadian Medical Association Alberta Medical Association University of Michigan Medical School Michigan Quality Improvement Consortium Singapore Ministry of Health National Resource for Infection Control Patient UK Guideline links UK Ambulance Service Clinical Practice Guidelines RefHELP NHS Lothian Referral Guidelines Medline (with guideline filter) Driver and Vehicle Licensing Agency NHS Health at Work(occupational health practice)Sources of systematic reviews and meta-analyses The Cochrane Library: Systematic reviews Protocols Database of Abstracts of Reviews of Effects Medline (with systematic review filter) EMBASE (with systematic review filter)Sources of health technology assessments and economic appraisals NIHR Health Technology Assessment programme The Cochrane Library: NHS Economic Evaluations Health Technology Assessments Canadian Agency for Drugs and Technologies in Health International Network of Agencies for Health Technology AssessmentSources of randomized controlled trials The Cochrane Library: Central Register of Controlled Trials Medline (with randomized controlled trial filter) EMBASE (with randomized controlled trial filter)Sources of evidence based reviews and evidence summaries Bandolier Drug & amp; Therapeutics Bulletin TRIP database Central Services Agency COMPASS Therapeutic NotesSources of national policy Department of Health Health Management Information Consortium(HMIC)Patient experiences Healthtalkonline BMJ - Patient Journeys Patient.co.uk - Patient Support GroupsSources of medicines informationThe following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content. British National Formulary(BNF) electronic Medicines Compendium(eMC) European Medicines Agency(EMEA) LactMed Medicines and Healthcare products Regulatory Agency(MHRA) REPROTOX Scottish Medicines Consortium Stockley's Drug Interactions TERIS TOXBASE Micromedex UK Medicines Information Back to top Stakeholder engagement Stakeholder engagement Our policyThe external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:Clinical accuracy.Consistency with other providers of clinical knowledge for primary care.Accuracy of implementation of national guidance (in particular NICE guidelines).Usability.Principles of the consultation processThe process is inclusive and any individual may participate.To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.External reviewers are not paid for commenting on the draft topics.Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.All reviewers are invited to be acknowledged on the website.All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.StakeholdersKey stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.Stakeholders identified from the following groups are invited to review draft topics:Experts in the topic area.Professional organizations and societies(for example, Royal Colleges).Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer's Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.Guideline development groups where the topic is an implementation of a guideline.The British National Formulary team.The editorial team that develop MeReC Publications.Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.Patient engagementClarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:Topic selectionScoping of topicSelection of clinical scenariosFirst draft internal reviewSecond draft internal reviewExternal reviewFinal draft and pre-publicationOur lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals. Back to top Evidence exclusion criteria Evidence exclusion criteria Our policyScoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.Standard exclusions for scoping literature:Animal studiesOriginal research is not written in EnglishPossible exclusions for reviewed literature:Sample size too small or study underpoweredBias evident or promotional literaturePopulation not relevantIntervention/treatment not relevantOutcomes not relevantOutcomes have no clear evidence of clinical effectivenessSetting not relevantNot relevant to UKIncorrect study typeReview articleDuplicate reference Back to top Organizational, behavioural and financial barriers Organizational, behavioural and financial barriers Our policyThe CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.FeasibilityStudies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.Organizational and Financial Impact AnalysisStudies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.Eligible populationCurrent interventionsLikely uptake of new intervention or recommendationCost of the current or new intervention mixImpact on other costsCondition-related costsIn-direct costs and service impactsTime dependenciesCost-effectiveness or cost-benefit analysis studies are identified where available. We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation. Back to top Declarations of interest Declarations of interest Our policyClarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:Personal financial interestsPersonal family interestPersonal non-financial interestNon-personal financial gain or benefitAlthough particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons.An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.Who should declare competing interests?Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.Competing interests declared for this topic:None. References Back to topReferences ABPI (2011) SPC for Efexor XL. Electronic Medicines Compendium. Datapharm Communications Ltd.. www.medicines.org.uk [Free Full-text] ABPI (2013a) SPC for Manerix 300mg. Electronic Medicines Compendium. Datapharm Communications Ltd.. www.medicines.org.uk [Free Full-text] ABPI (2013b) SPC for Prozac 20mg hard capsules, and 20mg per 5ml oral liquid. Electronic Medicines Compendium. Datapharm Communications.. www.medicines.org.uk [Free Full-text] ABPI (2013c) SPC for Zispin SolTab 15mg, 30mg and 45mg Orodispersible Tablets. 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