Assessing a person with depressive symptoms

Occasional depressive symptoms (eg low mood, sadness) are part of the general human condition. They are a normal response to life events or can occur for no apparent reason. If depressive symptoms are prolonged or excessive, they can become maladaptive and impair function, becoming clinically significant.

Assess a patient with depressive symptoms—see Assessing a patient with depressive symptoms. The aim of assessing a patient with depressive symptoms is to:

  • aid diagnosis
  • determine the patient’s safety and suicide risk
  • detect comorbid conditions
  • establish a robust patient–clinician relationship, which is central to the success of treatment.
Figure 1. Assessing a patient with depressive symptoms

There are multiple steps in assessing a patient with depressive symptoms.

Identify the cause:

Depressive symptoms can have various causes—see here. Consider diagnoses including:

Assess the patient’s safety:

  • Assess the risk of suicide, self-harm and harm/neglect to others (especially in perinatal depression)—see Suicide risk.
  • Refer to a psychiatrist or mental health service if there are any concerns about safety of the patient or others, but do not delay treatment to do so; refer to an acute mental health service if the safety risk is immediate.

Determine the presence of comorbidities:

  • Comorbid anxiety—if the onset of anxiety and depressive symptoms are concurrent, anxiety is likely to resolve with effective treatment of the depressive disorder. If anxiety predates the onset of depressive symptoms, treat anxiety concurrently (see Anxiety and associated disorders).
  • Comorbid insomnia or other sleep disorders—sleep disorders, particularly obstructive sleep apnoea and insomnia, are common in people with major depression and can worsen depressive symptoms; assess and treat accordingly (as relevant, see Obstructive sleep apnoea in adults, Sleep-disordered breathing in children, Assessing an adult with insomnia or Sleep problems in children and adolescents).
  • Comorbid substance abuse—concurrently manage substance abuse and depression, preferably with a multidisciplinary team (see Alcohol and other drug problems). Alcohol has a powerful depressogenic effect; drinking alcohol decreases the effectiveness of antidepressants.
  • Other medical conditions—assess and treat the comorbidity (eg cerebrovascular disease, hypothyroidism) concurrently.

Determine psychosocial contributors:

  • Psychosocial contributors—ask about stressful situations/events (eg relational, occupational, financial or legal problems; domestic violence; gambling problems).
  • Premorbid personality—assess the patient’s usual coping styles.

When assessing an older patient with depressive symptoms, also consider alternative explanations that become more common in older age, such as:

  • psychomotor and affective changes in Parkinson disease
  • pseudobulbar affect (tearfulness and emotional lability) from stroke
  • normal sadness caused by bereavement or loss of independence due to age-related disabilities (see Grief)
  • behavioural changes and cognitive impairments accompanying delirium and dementia.

When assessing a child with depressive symptoms also consider that:

  • information should be obtained from the child, as well as their parents or carers, and teachers
  • irritability may be a prominent symptom of depression in children
  • the risk of suicidal behaviour increases sharply after the onset of puberty, especially for males.

See the following topics for additional considerations in assessing depressive symptoms in: