Understanding, Assessing and Treating Depression

Overview of depression

Depression is a common and serious mental illness characterised by persistent feelings of sadness, hopelessness, and a loss of interest in activities that a person typically enjoys. These feelings can interfere with a person's ability to work, study, and engage in daily activities, and can lead to a variety of emotional and physical problems.There are several types of depression, including:<ul><li>Major depressive disorder: A severe form of depression that lasts for at least two weeks and is characterised by a number of symptoms that interfere with a person's ability to work, study, and engage in daily activities.</li><li>Persistent depressive disorder: A form of depression that lasts for at least two years.</li><li>Substance/medication-induced depressive disorder: A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterised by depressed mood or markedly diminished interest or pleasure in all, or almost all, activities.</li><li>Premenstrual dysphoric disorder: A form of depression that occurs when, for most menstrual cycles, a woman has at least five symptoms in the week before the onset of menses, starts to improve within a few days after the onset of menses, and experiences minimal or no symptoms in the week postmenses.</li></ul>Depression can affect people of all ages and backgrounds, and it is a leading cause of disability worldwide. It is estimated that about 16.2 million adults in the United States (6.7% of the adult population) had at least one major depressive episode in 2016.The exact cause of depression is not fully understood, but it is believed to be the result of a combination of genetic, environmental, and psychological factors. Some people may be at a higher risk of developing depression due to certain life events or experiences, such as trauma, abuse, or the loss of a loved one.

What is depression?

According to the DSM-5-TR (the latest edition of the Diagnostic and Statistical Manual of Mental Disorders), depression is defined as a mood disorder characterised by persistent feelings of sadness, hopelessness, and a loss of interest in activities that a person typically enjoys. These feelings must be present for at least two weeks and be severe enough to interfere with a person's ability to work, study, and engage in daily activities.In order to be diagnosed with depression, an individual must also experience at least five of the following symptoms:<ul><li>Persistent feelings of sadness, emptiness, or hopelessness</li><li>Loss of interest or pleasure in activities that were once enjoyable</li><li>Decreased energy or fatigue</li><li>Difficulty concentrating, remembering, or making decisions</li><li>Insomnia or excessive sleeping</li><li>Changes in appetite or weight</li><li>Feelings of worthlessness or guilt</li><li>Thoughts of death or suicide</li></ul>

What are the symptoms of depression?

It is important to remember that depression can manifest differently in each individual and the symptoms may vary in intensity and duration. An individual experiencing symptoms of depression should seek help from a mental health professional.

1
For physical symptoms:

Fatigue or low energy; changes in appetite and weight; sleep disturbances (insomnia or excessive sleeping); aches and pains, headaches, or digestive problems that do not improve with treatment; restlessness and agitation.
2
For emotional symptoms:

Feelings of sadness, hopelessness, or helplessness; irritability and frustration; loss of interest or pleasure in activities once enjoyed; feelings of worthlessness or guilt; difficulty concentrating or making decisions; thoughts of death or suicide.
3
For behavioural symptoms:

Withdrawal from social activities and relationships; lack of motivation or interest in daily activities; decreased physical activity or increased physical inactivity; substance abuse; poor work or school performance.

How to diagnose depression

Mental health professionals can use several diagnostic tools to assess for depression. These can help a professional determine the severity of an individual's symptoms and make a diagnosis of depression.

Some examples of diagnostic tools for depression include:

DSM-5-TR criteria

The DSM-5-TR is a manual used by mental health professionals to diagnose mental disorders. It provides a list of criteria that must be met in order to diagnose depression.

Patient Health Questionnaire (PHQ-9):

The PHQ-9 is a self-report questionnaire that can be used to assess the severity of an individual's depression symptoms. It consists of nine questions that ask about the frequency and severity of symptoms such as depressed mood, loss of interest, and changes in sleep and appetite.

Beck Depression Inventory, Second Edition (BDI-II):

The BDI is a self-report questionnaire that consists of 21 questions that assess an individual's symptoms of depression. It asks about symptoms such as depressed mood, loss of pleasure, and feelings of guilt.

Hamilton Depression Rating Scale (HDRS):

The HDRS is a clinician-administered assessment tool that consists of 17 questions assessing an individual's symptoms of depression. It asks about symptoms such as depressed mood, loss of pleasure, and changes in sleep and appetite.

International Classification of Diseases (ICD-11):

The ICD is a standardised system for classifying and coding diseases and related health conditions. It is published by the World Health Organisation (WHO) and is used in many countries around the world as a standard diagnostic tool for epidemiology, health management, and clinical purposes. The ICD-11 includes codes for a variety of mental disorders, including depression. Mental health professionals can use the ICD-11 codes to diagnose and classify depression and other mental disorders. The ICD codes can be used to identify patterns and trends in mental health conditions, and to develop treatment and prevention strategies.

Common treatment approaches for depression

It is important to note that treatment for depression often involves a combination of approaches, and the most effective treatment will vary from person to person. A mental health professional can help an individual develop a treatment plan that is tailored to their specific needs and goals.

Several different treatment approaches are commonly used to help individuals manage depression. These may include:

Medication

Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and monoamine oxidase inhibitors (MAOIs), can be effective in reducing symptoms of depression.

Psychotherapy

Different types of psychotherapy that may be used to treat depression include cognitive-behavioural therapy (CBT), interpersonal therapy (IPT), and dialectical behaviour therapy (DBT).

Mindfulness and relaxation techniques

Practices such as mindfulness meditation, progressive muscle relaxation, and deep breathing can help individuals with depression reduce stress and improve their overall well-being.

Lifestyle changes

Making changes to one's diet, exercise routine, and sleep habits can be helpful in managing symptoms of depression.

Transcranial magnetic stimulation (TMS)

TMS is a non-invasive treatment that uses magnetic fields to stimulate specific areas of the brain. It is typically used for individuals with depression who have not responded to other treatment approaches.

Alternative treatments

Some individuals with depression may find relief with alternative treatments such as herbal supplements, acupuncture, or light therapy.

Best practice treatment guides for depression

There are several best practice treatment guides for depression that provide recommendations for the assessment and management of the disorder. Some of the most well-known guides include:<ul><li>National Institute for Health and Care Excellence (NICE): NICE is a UK-based organisation that provides evidence-based guidance on the treatment and management of health conditions, including depression. Their guideline on the treatment and management of depression in adults can be found <a target='_blank' href='https://www.nice.org.uk/guidance/ng222'>here</a>.</li><li>Australian Clinical Guidelines for Depression and Related Disorders: This guideline, published by the Royal Australian and New Zealand College of Psychiatrists, provides recommendations on the assessment, treatment, and management of depression in adults and adolescents. The guideline can be found <a target='_blank' href='https://www.ranzcp.org/practice-education/guidelines-and-resources-for-practice'>here</a>.</li><li>American Psychiatric Association (APA) Practice Guidelines: The APA publishes practice guidelines for the treatment of various mental disorders, including depression. The guideline on the treatment of patients with major depressive disorder can be found <a target='_blank' href='https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf'>here</a>.</li><li>World Health Organisation (WHO): The WHO provides guidelines on the management of mental disorders, including depression. Their guideline on the management of depression can be found <a target='_blank' href='https://www.who.int/health-topics/depression#tab=tab_1'>here</a>.</li></ul>

Common comorbidities with depression

Depression often co-occurs with other mental and physical health conditions. These conditions are known as comorbidities. Some common comorbidities of depression include:<ul><li>Anxiety disorders: Depression often occurs alongside anxiety disorders such as generalised anxiety disorder, panic disorder, and phobias.</li><li>Substance abuse disorders: Depression is often comorbid with substance abuse disorders, including alcoholism and drug addiction.</li><li>Bipolar disorder: Depression is a symptom of bipolar disorder, which is characterised by periods of depression and periods of mania or hypomania.</li><li>Physical health conditions: Depression can co-occur with a variety of physical health conditions, including heart disease, diabetes, and cancer.</li><li>Eating disorders: Depression is often comorbid with eating disorders such as anorexia nervosa and bulimia nervosa.</li></ul>When treating a patient with depression, clinicians need to consider the presence of any comorbidities, as they can have a significant impact on the patient's treatment and overall well-being. Some things that clinicians should consider when treating a patient with depression and comorbidities include:<ul><li>The impact of comorbidities on treatment: Comorbidities can affect the effectiveness of treatment for depression and may require additional interventions. For example, an individual with both depression and an anxiety disorder may benefit from a treatment plan that includes both antidepressant medication and therapy for anxiety.</li><li>The need for coordinated care: It is important for clinicians to co-ordinate care with other healthcare providers to ensure that all of the patient's health needs are being addressed. This may include working with a primary care physician or specialists to manage physical health conditions.</li><li>The risk of complications: Comorbidities can increase the risk of complications and may require additional monitoring and support. For example, an individual with both depression and substance abuse disorder may be at a higher risk of overdose and may require additional support to maintain sobriety.</li><li>The impact on prognosis: Comorbidities can affect the prognosis (outlook) for an individual with depression. It is important for clinicians to be aware of this and to take this into account when developing a treatment plan.</li></ul>Overall, it is important for clinicians to be aware of the presence of any comorbidities when treating a patient with depression, and to take a holistic approach to treatment that addresses all of the patient's mental and physical health needs. This may involve coordinating care with other healthcare providers and adapting the treatment plan as needed to ensure the best possible outcomes for the patient.

MHA courses on depression

<ul><li><a target='_blank' href='https://www.mentalhealthacademy.com.au/catalogue/courses/depression-symptoms-causes-and-treatment'>Depression: Symptoms, Causes, and Treatment</a></li><li><a target='_blank' href='https://www.mentalhealthacademy.com.au/catalogue/courses/using-motivational-interviewing-with-alcohol-dependence-and-depression'>Using Motivational Interviewing with Alcohol Dependence and Depression</a></li><li><a target='_blank' href='https://www.mentalhealthacademy.com.au/catalogue/courses/using-cbt-with-depression'>Using CBT with Depression</a></li><li><a target='_blank' href='https://www.mentalhealthacademy.com.au/catalogue/courses/treating-postnatal-depression-with-interpersonal-psychotherapy'>Treating Postnatal Depression with Interpersonal Psychotherapy</a></li><li><a target='_blank' href='https://www.mentalhealthacademy.com.au/catalogue/courses/treating-depression-with-motivational-interviewing'>Treating Depression with Motivational Interviewing</a></li><li><a target='_blank' href='https://www.mentalhealthacademy.com.au/catalogue/courses/autism-and-depression'>Autism and Depression</a></li><li><a target='_blank' href='https://www.mentalhealthacademy.com.au/catalogue/courses/treating-depression-in-older-adults'>Treating Depression in Older Adults</a></li><li><a target='_blank' href='https://www.mentalhealthacademy.com.au/catalogue/courses/adolescent-depression-a-biopsychosocial-approach'>Adolescent Depression: A Biopsychosocial Approach</a></li><li><a target='_blank' href='https://www.mentalhealthacademy.com.au/catalogue/courses/conducting-a-state-of-the-science-suicide-assessment-interview'>Conducting a State of the Science Suicide Assessment Interview</a></li><li><a target='_blank' href='https://www.mentalhealthacademy.com.au/catalogue/courses/therapeutic-lifestyle-changes-for-anxiety-and-depression'>Therapeutic Lifestyle Changes for Anxiety and Depression</a></li><li><a target='_blank' href='https://www.mentalhealthacademy.com.au/catalogue/courses/self-compassion-therapy-for-the-prevention-and-treatment-of-perinatal-mental-health-issues'>Self-compassion Therapy for the Prevention and Treatment of Perinatal Mental Health Issues</a></li><li><a target='_blank' href='https://www.mentalhealthacademy.com.au/catalogue/courses/when-it-is-darkest-understanding-suicide-risk'>When It is Darkest: Understanding Suicide Risk</a></li></ul>

Treatment resources for depression

<ul><li>Australian Government (Department of Health and Aged Care) – <a target='_blank' href='https://www.health.gov.au/resources/pregnancy-care-guidelines/part-e-social-and-emotional-screening/screening-for-depressive-and-anxiety-disorders'>Screening for Depressive and Anxiety Disorders</a></li><li>American Psychiatric Association (APA) – <a target='_blank' href='https://www.apa.org/depression-guideline/assessment'>Depression Assessment Instruments</a></li><li>The Centre for Addiction and Mental Health (CAMH) – <a target='_blank' href='https://www.camh.ca/en/professionals/treating-conditions-and-disorders/depression/depression---screening-and-assessment'>Depression: Screening & Assessment</a></li><li>The Centre for Addiction and Mental Health (CAMH) – <a target='_blank' href='https://www.camh.ca/en/professionals/treating-conditions-and-disorders/depression/depression---clinical-tools'>Depression: Clinical Tools & Resources</a></li><li>Mental Health America (MHA) – <a target='_blank' href='https://screening.mhanational.org/screening-tools/depression/'>Depression Test</a></li></ul>

Frequently asked questions about depression

It is important for a patient to work with their mental health professional to develop a personalised plan for managing their depression in daily life.

What are the typical patterns and triggers for symptoms of depression?

Symptoms of depression can vary from person to person, and the patterns and triggers for these symptoms can also vary. Some individuals may experience symptoms of depression consistently over time, while others may have periods of time when their symptoms are more severe or more manageable. Triggers for symptoms of depression can include life stressors such as loss, trauma, or significant life changes, as well as medical conditions or medications.

How does depression typically affect an individual's mood, energy levels, and motivation?

Depression is characterised by persistent feelings of sadness, hopelessness, and worthlessness, and can also affect an individual's energy levels and motivation. Some individuals with depression may experience a lack of energy and difficulty initiating or completing activities, while others may have fluctuations in their energy levels. Depression can also affect an individual's motivation, causing them to lose interest in activities that they previously enjoyed.

What are the common physical and cognitive symptoms of depression?

In addition to affecting mood and motivation, depression can also cause a variety of physical and cognitive symptoms. Physical symptoms of depression may include changes in appetite and weight, sleep disturbances, and fatigue. Cognitive symptoms of depression may include difficulty concentrating, difficulty making decisions, and slowed thinking.

How does depression typically impact sleep, appetite, and sexual functioning?

Depression can affect an individual's sleep patterns, causing them to experience difficulty falling asleep, staying asleep, or waking up feeling rested. It can also cause changes in appetite, leading to weight gain or weight loss. Depression may also impact an individual's libido and sexual functioning.

What are the potential complications of depression, such as self-harm and suicide?

Depression can have serious complications, including self-harm and suicide. It is important for individuals with depression to seek treatment as soon as possible in order to reduce the risk of these complications.

How does depression typically impact an individual's ability to work, study, and engage in daily activities?

Depression can have a significant impact on an individual's ability to function in daily life. It can affect an individual's ability to work, study, and participate in activities that they previously enjoyed.

What are the key indicators of progress in the treatment of depression, and how should a clinician assess these indicators?

When treating a patient with depression, it is important for a clinician to identify and monitor key indicators of progress in order to determine the effectiveness of the treatment plan. These indicators may include reductions in the severity and frequency of depression symptoms, improved functioning in daily activities, and an overall improvement in quality of life. A clinician can assess these indicators through a combination of self-report measures (such as symptom rating scales), observation, and reports from family members or other sources. By regularly tracking progress, a clinician can make adjustments to the treatment plan as needed to ensure the best possible outcomes for the patient.

Does depression increase a patient's likelihood of suicide, and if so, how can a clinician assess suicide ideation?

Yes, depression can increase a patient's likelihood of suicide. It is important for mental health clinicians to assess for suicide ideation (thoughts of suicide) in all patients with depression, as it is a key risk factor for suicide. Clinicians can assess for suicide ideation by asking directly about suicidal thoughts, as well as by looking for warning signs such as a change in mood, increased substance use, and statements indicating a desire to die.Clinicians may also use assessment tools, such as:<ul><li>Suicide Risk Assessment Form: This is a standardised assessment tool that includes a series of questions about a patient's suicidal thoughts, behaviours, and risk factors. It is typically completed by a mental health clinician during a clinical interview.</li><li>Suicide Status Form (SSF): The SSF is a brief assessment tool that can be used to quickly assess a patient's risk of suicide. It includes questions about the patient's current suicidal thoughts, past suicide attempts, and the presence of protective factors.</li><li>Suicide Risk Rating Scale (SRRS): The SRRS is a tool that can be used to identify patients at high risk of suicide. It includes questions about the patient's suicidal thoughts, behaviours, and risk factors, and assigns a score based on the responses.</li><li>Columbia-Suicide Severity Rating Scale (C-SSRS): The C-SSRS is a widely used assessment tool that can be used to assess a patient's risk of suicide. It includes questions about the patient's current and past suicidal thoughts, behaviours, and risk factors.</li></ul>These tools should be used as part of a comprehensive assessment and should not be used in isolation. It is always best to work with a mental health professional to determine the most appropriate assessment and treatment plan for an individual.

What strategies can a patient use to manage their depression in daily life?

There are a number of strategies that a patient with depression can use to manage their symptoms in daily life. Some strategies that may be helpful include:<ul><li>Adhering to treatment: It is important for a patient to follow their treatment plan as prescribed by their mental health professional. This may include taking medication as directed, attending therapy sessions, and participating in any recommended self-care activities.</li><li>Practising self-care: Taking care of physical and emotional needs can help a patient manage their depression symptoms. This may include getting enough sleep, eating a healthy diet, and engaging in activities that promote relaxation and stress management.</li><li>Connecting with others: Building and maintaining supportive relationships can be helpful in managing depression. This may involve reaching out to friends and family, joining a support group, or participating in activities with others.</li><li>Staying active: Engaging in regular physical activity can help improve mood and reduce stress. It is important for a patient to find an activity that they enjoy and to incorporate it into their daily routine.</li><li>Identifying and addressing negative thought patterns: Cognitive-behavioural therapy (CBT) can be helpful in identifying and changing negative thought patterns that contribute to depression. A patient can work with their mental health professional to develop strategies for identifying and challenging these thoughts.</li></ul>

Popular books on depression

<ul><li>The Noonday Demon: An Atlas of Depression (2015) by Andrew Solomon</li><li>A Cure for Darkness: The Story of Depression and How We Treat It (2022) by Alex Riley</li><li>An Unquiet Mind: A Memoir of Moods and Madness (2014) by Kay Redfield Jamison</li><li>Black Pain: It Just Looks Like We’re Not Hurting (2009) by Terrie Williams</li><li>Behavioural Activation for Depression: A Clinician's Guide (2009) by Christopher R. Martell, Sona Dimidjian & Ruth Herman-Dunn</li><li>Mindsight: Change Your Brain, Change Your Life (2012) by Daniel J. Siegel</li><li>Depression, Anxiety, and Other Things We Don’t Want to Talk About (2021) by Ryan Casey Waller</li><li>Full Catastrophe Living: How to Cope with Stress, Pain and Illness Using Mindfulness Meditation (2013) by Jon Kabat-Zinn</li><li>Furiously Happy: A Funny Book About Horrible Things (2015) by Jenny Lawson</li><li>Good Moms Have Scary Thoughts: A Healing Guide to the Secret Fears of New Mothers (2019) by Karen Kleiman & Molly McIntyre (Illustrator)</li><li>It’s OK That You’re Not OK: Meeting Grief and Loss in a Culture That Doesn’t Understand (2019) by Megan Devine</li><li>Learnt Hopefulness: The Power of Positivity to Overcome Depression (2020) by Dan Tomasulo & Scott Barry Kaufman</li><li>Lost Connexions: Why You're Depressed and How to Find Hope (2019) by Johann Hari</li><li>Maybe You Should Talk to Someone: A Therapist, Her Therapist, and Our Lives Revealed (2022) by Lori Gottlieb</li><li>Self-Compassion: The Proven Power of Being Kind to Yourself (2015) by Kristin Neff</li><li>Spark: The Revolutionary New Science of Exercise and the Brain (2012) by John J. Ratey & Eric Hagerman</li><li>The Antidote: Happiness for People Who Can’t Stand Positive Thinking (2013) by Oliver Burkeman</li><li>The Depression Cure: The 6-Step Programme to Beat Depression Without Drugs (2010) by Stephen Ilardi</li><li>The Happiness Trap: How to Stop Struggling and Start Living (2022) by Russ Harris</li><li>The Inflamed Mind: A Radical New Approach to Depression (2009) by Edward Bullmore</li><li>The Mindful Way Through Depression: Freeing Yourself from Chronic Unhappiness (2007) by J. Mark G. Williams, John Teasdale, Zindel Segal & Jon Kabat-Zinn</li><li>The Upward Spiral: Using Neuroscience to Reverse the Course of Depression, One Small Change at a Time (2015) by Alex Korb</li><li>This Is Depression: A Comprehensive, Compassionate Guide for Anyone Who Wants to Understand Depression (2019) by Diane McIntosh</li><li>Undoing Depression: What Therapy Doesn’t Teach You and Medication Can’t Give You (2021) by Richard O'Connor</li></ul>

Recent research on depression

<ul><li>Science Daily – <a target='_blank' href='https://www.sciencedaily.com/news/mind_brain/depression/'>Depression News</a></li><li>Nature Portfolio – <a target='_blank' href='https://www.nature.com/subjects/depression'>Depression</a></li><li>WebMD – <a target='_blank' href='https://www.webmd.com/depression/depression-latest-research'>Depression: Latest Research</a></li><li>National Institute of Mental Health (NIH) – <a target='_blank' href='https://www.nimh.nih.gov/news/science-news/science-news-about-depression'>Science News About Depression</a></li></ul>

References

<ul><li>American Psychiatric Association (APA). (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Washington, D.C., U.S.A.: APA. ISBN 978-0-89042-576-3</li><li>Healthline. (n.d.). Depression: Causes, Symptoms, Diagnosis, Treatment, and Prevention. Retrieved February 10, 2023, from <a href='https://www.healthline.com/health/depression#causes' target='_blank'>https://www.healthline.com/health/depression#causes</a>.</li><li>Mayo Clinic. (n.d.). Depression. Retrieved February 10, 2023, from <a href='https://www.mayoclinic.org/diseases-conditions/depression/diagnosis-treatment/drc-20356013' target='_blank'>https://www.mayoclinic.org/diseases-conditions/depression/diagnosis-treatment/drc-20356013</a>.</li><li>Mayo Clinic. (n.d.). Depression: Symptoms and Causes. Retrieved February 10, 2023, from <a href='https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007' target='_blank'>https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007</a>.</li><li>WebMD. (n.d.). What is Depression? | Understanding Sadness and Clinical Depression. Retrieved February 10, 2023, from <a href='https://www.webmd.com/depression/guide/what-is-depression' target='_blank'>https://www.webmd.com/depression/guide/what-is-depression</a>.</li></ul>

Understanding, Assessing and Treating Depression

Guidelines, tools and resources for mental health clinicians

Jump to section

Overview of depression

What is depression?

What are the symptoms of depression?

For physical symptoms:

For emotional symptoms:

For behavioural symptoms:

How to diagnose depression

Common treatment approaches for depression

Best practice treatment guides for depression

Common comorbidities with depression

MHA courses on depression

Treatment resources for depression

Frequently asked questions about depression

Popular books on depression

Recent research on depression

References