Depression

Diagnosis

 Symptoms & presentation
 Subtypes of depression
 Single episode and recurrent
 Psychiatric rating scales

Symptoms & Presentation

There are many misconceptions about depression. It is important to know that depression is not:

• just feeling 'a bit down'
  - depression has a profound effect on everyday life
• a sign of weakness
  - depression is ultimately caused by an imbalance of neurotransmitters , though personality and life events resulting in stress may have contributed to the imbalance
• a 'punishment' because one is a bad person
  - depression is an illness that can affect anyone
• something to feel guilty about
  - remember, it is not the person's fault.

The psychological and biological symptoms that a person with depression may present with are:

Psychological

• dejected, unhappy mood, often worst in the mornings
• anxiety or irritability
• lack of interest or enjoyment in everyday life
• withdrawal from the outside world
• general slowing of mental activity
• indecision and difficulty in thinking clearly
• loss of concentration and poor memory
• loss of interest in dress and appearance
• feelings of guilt, which sometimes become delusional
• hypochondria
• loss of libido
• restless preoccupation with morbid, pessimistic thoughts
• feeling that there is no future, and thoughts of suicide.

Biological

• sleep disturbance (usually waking early and being unable to get back to sleep)
• lack of appetite and weight loss (but sometimes overeating occurs)
• constipation
• unexplained pains or aching discomfort anywhere in the body
• constant fatigue and listlessness.

Factsheet: Diagnosis of mental disorders

Subtypes of Depression

Primary vs Secondary Depression

This is a classification based on the supposed aetology of the depressive symptoms. It distinguishes:

• primary depression - depression that has no obvious physical or psychological cause
• secondary depression - depression that seems to be caused by some other underlying condition.

This classification was developed originally for research reasons, when it was expected that the two types might differ in their symptoms and response to treatment. In practice this has not been found to be the case and, for this reason, the classification is no longer widely used.

Endogenous vs Reactive Depression

This is another aetiological classification. It identifies:

• endogenous depression, which - like primary depression - arises 'from within'
• reactive depression (sometimes called exogenous depression), which arises following an unhappy life event such as bereavement, divorce or redundancy.

This scheme is little used by psychiatrists these days, because in practice the causes of most cases of depression seem to include both endogenous and reactive factors. Some physicians use it, believing that many of the depressions they identify as 'reactive' are likely to lift spontaneously, without drug treatment.

Psychotic vs Neurotic Depression

This is a classification based on symptoms. It differentiates between:

• psychotic depression, where the patient experiences intense symptoms such as hallucinations or delusions and is therefore felt to have lost touch with reality
• neurotic depression, where psychotic symptoms are absent, but which is accompanied by neurotic symptoms such as anxiety and phobia and some biological symptoms.

This scheme is still used by some physicians, and is widely understood, although its usefulness is frequently questioned.

Postnatal Depression

Depression that follows the birth of a child is called postnatal or postpartum depression. Episodes of mood disturbance following the birth of a child are common and may well take the form of either manic depression or major depressive disorder. The treatment and clinical presentation are very similar to typical cases of mania or depression, but the treatment is complicated by several issues. The first is that the woman may be breast-feeding and this may impact on the therapeutic options chosen, particularly those regarding medication. Second, not only does the woman's functional capacity and the ability to care for herself have to be evaluated, but her ability to look after her new baby and to establish a bond with the child must also be evaluated. Third, this is a time of tremendous social and physical stress. In fact, episodes of mania or depression are almost as common in fathers as they are in mothers following the birth of a child. These conditions are often missed because of the great disruption in sleep and activity that comes with having a new baby.

Atypical Depression

This is a specific subtype of depression that does not fulfil other depression subtype criteria. Atypical depression is characterised by mood reactivity (when a patient's mood reacts sharply to a specific situation, good or bad), significant weight gain or increased appetite, hypersomnia (excessive sleeping), psychomotor retardation and high sensitivity levels of interpersonal rejection resulting in social or occupational impairment. These patients respond slowly to antidepressant treatment and upon failing to respond to SSRIs often patients respond well to MAOIs.

Psychotic Depression

Psychotic depression is a type of major depression, when the person also has depressive thoughts or beliefs that do not conform to reality. Thinking is very disorganised and delusions may occur. Sometimes, hallucinations are present. In psychotic depression, delusions or hallucinations are 'mood congruent'. That means the hallucinations and delusions harmonise with aspects of the person's mood. For example, the unrealistic belief that someone else may want to harm them fits with the symptoms of low self-esteem and feelings of worthlessness. Psychotic depression can be episodic or chronic. About 1 in 10 people with major depression will have psychotic symptoms. Psychotic depression is characterised by greater severity, higher rate of recurrence, greater impairment, more frequent hospitalisation, and longer episodes than non-psychotic depression. The use of combined TCAs and antipsychotic medication as well as electroconvulsive therapy, has been proven effective. There is also evidence for efficacy of SSRIs, alone and in combination with antipsychotics, in psychotic depression.

Dysthymia

This is a condition recognised in DSM-IV that does not quite fit the 'conventional' depression pattern: patients have fewer and less intense symptoms than in major depression, but the whole episode has a longer duration - patients are depressed for most of the time for at least 2 years. It is quite common in younger patients, but its onset may be difficult to identify accurately. Despite the less severe symptoms in dysthymia, there is still an increased risk of suicide.

When a patient with dysthymia develops depressive symptoms sufficient to fulfil the criteria for major depression, the diagnosis of 'double depression' is made.

Single Episode and Recurrent

This describes depression in terms of its frequency:

• single episode depression describes those cases where patients experience only one episode of depression and remain 'normal' thereafter
• recurrent depression describes the situation where a patient experiences two or more episodes of depression, separated by at least 2 months of essentially 'normal' function.

Both DSM-IV and ICD-10 make a distinction between single episode and recurrent disorders.

Psychiatric Rating Scales

Depression severity is often simply defined as 'mild', 'moderate' or 'severe'. It is necessary to understand these descriptions in terms of the extent to which the patient's everyday life is affected:

Mild depression causes only minor impairment of the patient's work, social life and relationships with others. Remember that major depression can be of mild severity. Moderate depression is associated with more obvious symptoms and is likely to be noticeable to others. Severe depression produces symptoms that affect the patient so badly that he or she may be unable to work or to relate socially to others.

The severity of depression can be measured objectively using depression-rating scales. There are many rating scales used for the measuring of the severity of disorders in psychiatry.

For depression the common rating scales are the:

• Hamilton Depression Rating Scale (Ham-D)
• Montgomery-Åsberg Depression Rating Scale (MADRS)
• Geriatric Depression Scale (GDS)
• Zung Self Rating Scale for Depression

For mania the most commonly used rating scale is:

• Young Mania Rating Scale

For anxiety the common rating scale is the:

• Hamilton Anxiety Rating Scale (Ham-A)

For OCD the common rating scale is the following:

• Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

For schizophrenia the common rating scales are the:

• Positive and Negative Symptom Scale (PANSS)
• Brief Psychiatric Rating Scale (BPRS)
• Calgary Depression Scale (CDS)

Other general psychiatry scales include the:

• Global Assesment of Functioning (GAF)
• Clinical Global Impression (CGI)

Hamilton Depression Rating Scale (Ham-D)

A commonly used scale to assess the severity of depression. The scale was developed for use primarily on patients who have already been diagnosed as suffering from affective disorders. There are two adaptations of this scale using 21 or 17 items (HAM-D ₂₁ ) and (HAM-D ₁₇ ) where the 17-item scale only uses the first 17 questions of the full scale. Item 18 is divided into two separate questions a and b. Question b is not part of the original scale and therefore does not count in the total score. Questions are related to symptoms such as depressed mood, guilty feelings, suicide, sleep disturbances, anxiety levels and weight loss (Hamilton, 1960).

Montgomery-Åsberg Depression Rating Scale (MADRS)

Originaly a subscale of the Comprehensive Psychopathological Rating Scale which was developed by Montgomery and Åsberg (1979). This scale has been designed to measure the treatment changes of depression. It measures the severity of many symptoms of depression such as mood and sadness, tension, sleep, appetite, energy, concentration, suicide and restlessness (Montgomery and Åsberg, 1979).

Young Mania Rating scale

This eleven item scale is intended to be administered by a trained clinician. A severity rating is given for each of the items based on the interview with the patient.

Hamilton Anxiety Rating Scale (Ham-A)

This scale consists of 14 items, each defined by a series of symptoms. As one of the first rating scales developed to measure the severity of anxiety symptomatology it has become a widely used and accepted outcome measure for the evaluation of anxiety in clinical trials. The scale was introduced by Max Hamilton in 1959 and measures the severity of anxiety symptoms such as anxiety, tension, depressed mood, palpitations, breathing difficulties, sleep disturbances, restlessness and other physical symptoms (Hamilton, 1959).

Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

A ten-item balanced scale designed to rate the severity and type of symptoms in patients with Obsessive-Compulsive Disorder (OCD). Includes measures of time occupied, interference with ordinary social activities, degree of distress, resistance and control. This scale was designed to address the problems of other rating scales by being able to measure the severity of symptoms of obsessive-compulsive disorder but not influenced by the type of obsessions or compulsions (Gorman et al., 1989).

Positive and Negative Symptom Scale (PANSS)

The PANSS originated as a more rigorously operationalised method for evaluating positive, negative, and other symptom dimensions in schizophrenia. The PANSS measurement is derived from behavioural information observed during the interview plus a clinical interview and reports by primary care hospital staff or reports by family members (Kay et al., 1987).

The ratings provide summary scores on a 7-item positive scale, a 7-item negative scale and a 16-item general psychopathology scale. The PANSS ratings should be based on the totality of information pertaining to a specified period, normally identified as the previous week. Each of the 30 items is accompanied by a specific definition as well as detailed anchoring criteria for all seven rating points. These seven points represent increasing levels of psychopathology, as follows: 1, absent; 2, minimal; 3, mild; 4, moderate; 5, moderate severe; 6, severe; 7, extreme. In assigning ratings, a physician first considers whether a symptom is at all present, as judging by the item definition. If the item is absent, it is scored 1, whereas if it is present the physicain must determine its severity by reference to the particular criteria for the anchoring points. The highest applicable rating point is always assigned, even if the patient meets criteria for lower ratings as well. The rating points 2 to 7 correspond to incremental levels of symptom severity. They are keyed to the prominence of symptoms, their frequency during the observation phase, and above all their disruptive impact on daily living.

Brief Psychiatric Rating Scale (BPRS)

The BPRS is probably the most widely used rating scale in psychiatry. The BPRS has 16 items that can be rated from not present (0) to extremely severe (6) on symptoms such as Somatic concern, Anxiety, Depressive mood, Hostility, and Hallucinations (Overall and Boodman 1962).

The BPRS has 16 items that can be rated from not present (0) to extremely severe (6). A total pathology score can be obtained by adding the scores from each item. The scale is constructed essentially for schizophrenia states but also includes depression symptoms. Interpretation of the total scale scores is 0-9, not a schizoaffective case; 10-20, possible schizoaffective case; 21 or more, definite schizoaffective case. For schizophrenia states, the ten schizophrenia items on the BPRS should be summed.

Although individual psychiatrists will rate symptoms and behaviours somewhat differently, a major advantage of using the BPRS is that change can be documented using a shorthand method that is widely understood. A physician should assess the presence and degree on the individual items in terms of the patient's condition at the time of the interview, and evaluate the following six items, on the basis of the condition during the past 3 days: items 2 (psychic anxiety), 10 (hostility), 11 (suspiciousness), 12 (hallucinatory behaviour), 15 (unusual thought content) and 16 (blunted or inappropriate affect). When in doubt, a physician will solicit information from ward personnel or relatives.

The scale is quantitative; it was constructed for the sole purpose of rating the current clinical picture and it is not to be considered as a diagnostic tool. When the scale is used in repeated (weekly) ratings, each assessment must be independent of the others. Phiycisians should therefore avoid looking at or recalling former interviews and should not ask about changes that might have taken place since the last interview. They should refer to the patient's condition during the preceding 3 days. For all items each scale step encompasses the lower steps, for example, scale step '3' includes scale steps '2' and '1'. Normal function is always rated as '0'.

In most situations, the BPRS can be completed without adding much time to the psychiatric interview. Although the scales and item definitions take some time to learn, once a physician is familiar with them, they can be completed in about one minute at the end of the interview. The physician will either enter the ratings while the patient is with them or after the patient has left. Entering ratings in the patient's presence provides an opportunity to ask any questions they may have missed

Calgary Depression Scale (CDS)

Since existing depression scales were designed for the assessment of depression in non-psychotic patients, such scales have items that do not distinguish depressed from non-depressed psychotic patients. The Calgary Depression Scale was designed for the assessment of depression in schizophrenia. It measures the severity of symptoms such as depressed mood, hopelessness, guilt, insomnia and suicide (Addington et al., 1993).

Global Assesment of Functioning (GAF)

The reporting of overall function on Axis V (5) of the DSM-IV is performed using the Global Assessment of Functioning (GAF) Scale. The GAF scale may be particularly useful in tracking the clinical progress of individuals in global terms, using a single measure. The GAF scale is to be rated with respect only to psychological and occupational functioning.

Clinical Global Impression (CGI)

The CGI refers to the global impression of the patient and requires clinical experience with the syndrome under assessment. The concept of improvement refers to the clinical distance between the patient's current condition and that prior to the start of treatment. The CGI improvement-scale can be completed only following or during treatment. There are seven categories of severity ranging from "Not ill" to "Extremely severe".

Factsheet: Rating scales