First Glance

The clinical assessment includes an evaluation of the signs and symptoms of depression. It would involve establishing whether the person has a depressive disorder or not, and if present, the severity of the depressive features.

Symtomatic assessment

The assessment should be symptomatic and should assess

• Type of onset
• Level of depressed mood
• Significant evidence of change in behaviour
  • slowing of thought, speech or movement
  • marked sleep disturbance, especially early morning wakening
  • diurnal variation of mood, e.g. feeling worse during the morning
  • loss of appetite
  • weight loss
  • loss of general interest, and in sex
    
    • pathological guilt: overvalued and delusional
    • presence and severity of anxiety
    • presence and severity of agitation
    • presence of delusions and hallucinations
    • dangerousness (suicide, homicide, infanticide, self-neglect)

This must be assessed at the first interview.

Physical examination

• Effect of other medical conditions on mood state and on any proposed antidepressant medication
• Full blood counts, ESR, blood urea and electrolytes, sugar, cholesterol, vitamin B12
• Thyroid function tests, T3, T4, TSH.
• Electrocardiogram · Other medical aspects
  • Current medication, licit or illicit (including barbiturates)
  • Depressant medication (including steroids, contraceptive pill)
  • Alcohol consumption.

Social assessment

Is the patient's response normal in the context of his situation? (e.g. bereavement). Look for difficulties and disasters in areas of :

• Health
• Sexual function
• Family
• Work
• Other relationships

Depressed patients are not as a rule socially isolated. Therefore, the psychiatrist should concentrate on the following factors in assessing the social network of the patient :

• Relationships as a source of strain and of support
• Any counter-productive effect of the patient on those who are close to him
• Interaction between the patient and his relatives
• The family's perception of the illness and expectations from the patient's treatment.

Assessment of the patient's social performance ideally requires an informant. What is the patient's usually level of performance in the following role?

• Relationships
• Practical management
• Work

Has there been a definite change in these related to the onset of illness ?

Screening for Depression

As is evident from the previous descriptions of depressive disorders it might be difficult to interview all patients in detail to detect depressive disorders. For such situations there are certain screening scales available for the detection of depression.

Some of these are in the form of scales like

• Hamilton's Depression Rating Scale (HDRS)
• Beck's Depression Inventory (BDI)
• Hospital Anxiety and Depression Scale (HADS)
• The General Health Questionnaire (GHQ)
  

Of these, the Hamilton and Beck's Depression scales are quite lengthy and time consuming. The GHQ is usually helpful in identifying individuals with psychiatric morbidity. The Hospital Anxiety and Depression Scale picks up symptoms of anxiety and depression in population from medical clinics and general practice. It is a 14- item scale with seven items measuring depression and seven items measuring anxiety.

Where it is not possible to administer any of the above scales, adding a few questions to the general interview might be useful. For example, asking a person how he has been feeling in his spirits or mood, or how he has been coping. Also, asking about the maintenance of interest in usual activities might be a useful strategy. One should enquire about disturbances of sleep, appetite and libido along with changes in mood and interests.

How to proceed with diagnosis ?

Patients with depression often present a confusing picture and pose management problems for the physician. In the absence of a straightforward complaint about depressed mood and in the presence of many somatic complaints,it seems quite natural to pursue organic causes for the patient's complaints. The distinction between "organic" and "psychological" causes is spurious. In the end, depression which people complain of in 'psychological' terms is the result of pathophysiological brain function which is as yet poorly understood. Physicians are increasingly aware of the many different presentations of depression and consideration of depression as an explanation for the patient's complaints has risen higher on most physicians lists of common medical problems.

Once the possibility of depressive illness has been recognized, physicians can often move fairly quickly to confirm their suspicions and institute appropriate antidepressant treatment. Masked depression can sometimes be uncovered by the use of depression questionnaires. A carefully conducted interview which explores the status of mood, thinking, vegetative functioning and general behaviour will usually provide the data necessary for a differential diagnosis among the depressive disorders. History-taking of this kind is best done in an unhurried and uninterrupted fashion. This pattern of history taking may be difficult to arrange on short notice in a busy practice, but detailed history of this kind is just as useful as a detailed general history and complete physical examination. A careful psychiatric history can often be scheduled in a block of time usually reserved for a complete medical history and physical examination.

After obtaining the patient's permission, contact with relatives is often helpful in confirming the patient's reports of either behaviour and sometimes in providing additional observations which the patient has failed to notice or report. Once the database has been obtained, processing it in a suitably systematic and efficient fashion is clearly the next step and critically important since choice of treatment can differ substantially depending on diagnostic subtype.