Assessing Depression

Medical Reviewer

In a typical busy family practice the doctor might allocate 10-15 minutes for each patient. Despite the fact that nearly 25 percent of the patients they see will have a primary problem involving anxiety and/or depression, various barriers may exist that hamper proper assessment. In this Sharepost I begin by outlining a couple of the standard procedures for assessing depression before returning to some of the associated problems.

A variety of protocols and procedures exist for the measurement of depression. Although clinicians may apply DSM or ICD criteria, it remains the case that a good level of judgment is applied during the assessment process. Researchers into depression tend to use standardized questionnaires and interviews to ensure some level of consistency in their findings. Perhaps not surprisingly many clinicians use a similar approach, mainly in the knowledge that standardized techniques will add a good measure of validity and reliability to their conclusions.

One of the most frequently used measures of depression severity is the interviewer-rated Hamilton Rating Scale for Depression (HRSD). Various refinements have been made to the original scale which was first developed in 1960. Like similar scales, the items cover issues of mood, behavior, cognitive and somatic (physical) symptoms, all know to be affected during depression. Many clinicians like using the HRSD because it is sufficiently sensitive to changes in severity of depression. This means it becomes a useful tool by which to measure the effectiveness of therapy.

Self-report measures are another popular way to assess depression. Probably the most popular method is through the use of the Beck Depression Inventory (BDI). For each question asked the respondent rates their feelings for the past week against pre-set statements. For example, "I do not feel sad" to "I am so sad or unhappy that I can't stand it". Once completed, each item is scored from 0 to 3, and the total represents the severity of depression. So, on the BDI-II scale for example, a score of 0-13 represents normality, 14-19 represents a mild depression, 20-28 a moderate depression and 29-63 a severe level of depression. The BDI is not intended to do anything beyond reflecting the severity of depression.

Despite laying out what appear to be fairly useful tools for assessing depression, or at least some component of it, it remains the case that many cases of depression are not seen for what they are. One of the most obvious hurdles is time, but both the patient and the doctor may present blocks to the assessment of depression.

When a patient visits the doctor the chances of them sitting down and saying 'I think I'm depressed', are actually fairly slim. With no prior experience of depression and nothing to compare it to, the natural inclination for the patient is to look for causes, and these are frequently physical. Time then is spent going through symptoms of feeling unwell. This is not deliberate evasion on the part of the patient, as much as a genuine belief that their symptoms, especially their emotional state, are due to some physical ailment.

The doctor in turn may have relatively little experience in the recognition and treatment of mental illness. We also can't dismiss the fact that their own beliefs have a bearing on their assessment of depression and its significance. Often a diagnosis of depression is made after other avenues have been exhausted. To some extent this is necessary as depression is often a symptom of physical conditions that first need to be ruled out, but with depression time is the enemy. Unfortunately there is evidence to suggest that when people do present with combined symptoms of depression and some physical ailment, the emphasis for treatment is frequently directed towards the ailment rather than the depression.

Knowing that such a high proportion of visits to the doctor involve anxiety or depression suggests more active screening is necessary as part of the routine clinical consultation. Many tools, a few of which have been outlined, exist to help doctors in this task.