Step 1 - NICE guidance - recognition of depression in primary care and general hospital settings

Last edited 08/2018 and last reviewed 06/2022

Step 1: recognition, assessment and initial management

• identifying people with depression
  • health professionals should be alert to possible depression (particularly in people with a past history of depression or a chronic physical health problem with associated functional impairment) and consider asking:
    • during the last month, have you often been bothered by:
      • feeling down, depressed or hopeless?
      • having little interest or pleasure in doing things?
        
        
  • if the person answers 'yes' to either question
    • a practitioner who is competent in mental health assessment should:
      • review the person's mental state and associated functional, interpersonal and social difficulties
      • consider using a validated measure for symptoms, functions and/or disability
      • for people with language or communication difficulties, consider using the Distress Thermometer and/or asking a family member or carer about symptoms; if significant distress is identified
    • a practitioner who is not competent in mental health assessment should:
      • refer the person to an appropriate professional - if this is not the person's GP, inform the GP
        
        
  • if the person also has a chronic physical health problem:
    • ask three further questions to improve the accuracy of the assessment:
      • during the last month, have you often been bothered by:
        • feelings of worthlessness?
        • poor concentration?
        • thoughts of death?
    • consider the role of the physical health problem and any prescribed medication in the depression
    • check that the optimal treatment for the physical health problem is being provided and adhered to; seek specialist advice if necessary
      
      
• assessment and initial management
  • for a person who may have depression, conduct a comprehensive assessment that does not rely simply on a symptom count. Take into account:
    • the degree of associated functional impairment and/or disability
    • the duration of the episode
  • health professionals should explore how the following may have affected the development, course and severity of the depression:
    • history of depression and comorbid mental health or physical disorders
    • any past history of mood elevation
    • response to previous treatments
    • the quality of interpersonal relationships
    • living conditions and social isolation
  • if the person has a learning disability or acquired cognitive impairment:
    • consider consulting a relevant specialist when developing treatment plans
    • where possible, provide the same interventions as for other people with depression; adjust the method of delivery or duration if necessary
  • always ask a person with depression directly about suicidal ideation and intent. If there is a risk of self-harm or suicide:
    • assess whether they have adequate social support and are aware of sources of help
    • arrange help appropriate to the level of risk
    • advise them to seek help if the situation deteriorates

Risk assessment and monitoring

• if the person presents considerable immediate risk to themselves or others, refer them urgently to specialist mental health services
• advise the person and their family or carer of the following, and ensure they know how to seek help promptly if required:
  • the potential for increased agitation, anxiety and suicidal ideation early in treatment; actively seek out these symptoms and review treatment if they develop marked and/or prolonged agitation
  • the need to be vigilant for mood changes, negativity, hopelessness and suicidal ideation, particularly when starting or changing treatment and at times of increased stress
• If the person is assessed to be at risk of suicide, consider:
  • take into account toxicity in overdose if an antidepressant is prescribed or the person is taking other medication; if necessary, limit the amount of drug(s) available
  • consider increasing the level of support, such as more frequent direct or telephone contacts
  • consider referral to specialist mental health services

For more detailed information then consult full guideline (1).

Reference:

1. NICE (April 2018). Depression.