• Primary Care
• Initial Assessment
• Pathways to Care
• Clinical Pathways
• Monitoring
• Patient Preference
• Professional Roles
• Audit and Monitoring

Initial Assessment

Many patients present in primary care with depression, and a proportion go unrecognised. The NES specification states that depression should be diagnosed using a combination of evidence-based diagnostic tools as well as clinical judgement.

Depression can be a sensitive subject area and the key is the effective use of communication skills combined with a systematic approach to assessment.

PHASES OF THE ASSESSMENT PROCESS

There are three distinct phases to the assessment process:

1. Screening: the identification of probable cases
2. Assessment and categorisation: clarification of diagnosis and severity of problem
3. Patient education & shared decision making: information sharing regarding diagnosis and treatment options, and a preliminary decision about plans for future treatment

PHASE 1: SCREENING

Routine screening may improve both the recognition and outcome of depression in some patient groups. NICE recommends primary care routinely screens certain high risk groups:

• Patients with significant physical illness
• Patients with other mental health problems, such as dementia
• Patients suffering major life events, such as childbirth, long-term or recent unemployment and bereavement
• Patients with a history of relationship difficulties and physical, sexual or emotional abuse

Appendix 1 shows recommended questions for use in identifying possible cases of depression, and Appendix 2 details recommended screening tools

Primary care will need to develop protocols that set out the procedures for implementing and auditing the screening in high-risk groups.

PHASE 2: ASSESSMENT AND CATEGORISATION

If screening identifies a possible depression, a more comprehensive assessment must be conducted. This may be most appropriately done by the GP, but could be completed by a variety of appropriately trained health professionals. This assessment should involve standardised measures of:

• Severity of depression
• Risk
• Other relevant psychosocial factors
• Ruling out of other causes (i.e. testing thyroid function)

The use of a standardised proforma to record this information is a necessary part of the NES model for depression.

Severity

A number of different methods can be used to categorise the severity of depression. Appendix 3 details an assessment of the severity of depression according to the ICD-10 checklist.

NICE recommends the categorisation of patients by mild, moderate or severe levels of depression. A categorisation tool such as the ICD-10 can help determine the appropriate type of treatment. It is also recommended that patients complete a selfreport questionnaire such as the PHQ-9 (Appendix 9), so that this can also be used as a measure of progress throughout treatment.

Risk

Suicidal thoughts are very common in depression. Patients with depression should always be asked directly about suicidal thoughts and intent. Possible questions to ask when assessing risk are included in Appendix 4

Other relevant factors

The assessment should also include questions relating to:

• Previous mental health problems including treatment and outcome.
• Family history of mental health problems
• Associated disability
• Availability of social support
• Social problems (family disputes, financial, employment)
• Alcohol (see CAGE questions in Appendix 5) and drug use.

PHASE 3: PATIENT EDUCATION

There is still a significant stigma associated with depression, and patients may be initially unwilling to accept the diagnosis, and may not want to start or to continue treatment. This means there is a need for discussion with the patient about diagnosis and treatment options, with a view to gaining agreement about the treatment plan.

This will involve:

1. Feedback to patient on the outcome of the assessment
2. Providing patient information leaflets about depression, its treatment, useful management strategies (such as lifestyle changes: diet, exercise, sleep) and local services (see Appendix 6 for relevant resources)
3. Discussing treatment options. The initial focus of these discussions will concern whether an intervention is required or not. Patients who do not require or do not want an intervention will be invited back for a review with the GP in 2 weeks (step 1). Patients who do require an intervention will enter the model at an appropriate step based on their clinical need. This is explained in more detail in the next section.