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When assessing low mood, explore degree of functional impairment and risk thoroughly. Always screen for previous mania/hypomania or family history.
Key Knowledge
What is Depression?
What is depression?
Depression (major depressive disorder) is a common, disabling mental health condition, characterised by persistent low mood and loss of interest/pleasure, with accompanying physical and cognitive symptoms. In ICD-11 it falls under “single episode depressive disorder” (6A70) or “recurrent depressive disorder” (6A71).
A depressive episode is diagnosed when the following requirements are met:
Duration:
● Symptoms persist for at least 2 weeks.
Core Symptoms (at least one must be present):
● Depressed mood (depressed, sad, empty) present most of the day, nearly every day.
● Markedly diminished interest or pleasure in all or almost all activities (anhedonia).
Additional Symptoms (some or all, in addition to above):
● Noticeable fatigue or low energy
● Reduced concentration or ability to think clearly
●Reduced self-esteem or self-confidence
● Feelings of guilt or self-blame (may be excessive or inappropriate)
● Hopelessness about the future
● Recurrent thoughts of death or suicide, or suicide attempt
● Sleep disturbance (insomnia or hypersomnia)
● Significant changes in appetite or weight
● Psychomotor agitation or retardation (observable slowing or restlessness)
Functional Impairment:
● The symptoms cause clinically significant distress or impairment in personal, family, social, educational, occupational, or other important areas of functioning.
Severity Specifiers:
Mild: Individual distressed by symptoms, has some difficulty in continuing to function in one or more domains. There are no delusions or hallucinations.
Moderate: Several symptoms of a depressive episode are present to a marked degree, or a large number of depressive symptoms of lesser severity are present overall. The individual typically has considerable difficulty functioning in multiple domains.
Severe: Many or most symptoms of a depressive episode are present to a marked degree, or a smaller number of symptoms are present and manifest to an intense degree. The individual has serious difficulty continuing to function in most domains).
With psychosis: severe depressive episodes are further specified as with/without psychosis. Classically, depressive delusions are of guilt (e.g. responsibility for a global disaster)/ nihilism (e.g. insides are rotting, or that they are already dead) and hallucinations of a critical voice (accusing, blaming).
Exclusions:
There should be no history of manic, mixed, or hypomanic episodes
Review physical health history and consider organic causes of depression, e.g. hypothyroidism, Cushing’s syndrome, brain tumour
Differential Diagnosis for Depression
Bipolar Disorder (depressive phase)
● Episodes of mood elevation at other times, family history of BPAD
Persistent Depressive Disorder (Dysthymia)
● Chronic, milder depression ≥2 years (ICD-11: 6A72)
Adjustment Disorder
● Symptoms occur in response to a stressor, typically resolve within 6 months
Grief / Bereavement
● Associated with a loss. Mood fluctuates, self-esteem usually preserved. Not a mental disorder unless meets criteria for a Prolonged Grief Disorder (6B42) (more than 6 months at a minimum, and clearly exceeds expected social, cultural or religious norms for the individual’s culture and context).
Anxiety Disorders
● Overlap, but anxiety is often predominant/more distressing
Medical Causes
● Hypothyroidism, anaemia, chronic illness, neurological disease
Alcohol/Substance-Related
● Problematic drinking (may be primary or secondary to depression)
● Recent or ongoing substance/medication use
Psychotic Disorders
● Primary delusions/hallucinations, disorganisation
Risk Assessment in Depression
Risk assessment in depression: As with every risk assessment, you must consider risk to self, to others and from others.
To self:
● Self-neglect (hydration, nutrition, medication adherence, personal care)
● History/thoughts/acts of deliberate self-harm
● History of suicide attempt
● Passive or active suicidal ideation (assess intent e.g. preparatory steps, note)
To others:
● Functioning impairment and dependents (e.g. children)
● Thoughts of harm to others (especially if psychotic symptoms/ screen for thoughts of harm to baby in post-partum episodes)
From others:
● May be vulnerable to exploitation due to low self-volition
Also consider protective factors i.e. sense of responsibility (to family, pets), hope, religious or moral beliefs, social support systems. Risk is dynamic and should be regularly reviewed.
Communication Tips
● Use open, empathetic questions to build rapport.
● Explore symptoms systematically and impact on daily life.
● Be sensitive when discussing thoughts of deliberate self-harm or suicide, but also be specific and ask direct questions – you need to establish the level of risk. “Normalising” could be one strategy, i.e. “it’s common for people who are feeling depressed to feel hopeless and that life isn’t worth living, have you ever felt like this?”
CASC Practice Scenarios
Scenario 1: History Taking
Candidate Instructions
You are the core trainee in psychiatry in a community mental health clinic. You are asked to assess Mr. Andrew Green, a 29-year-old man referred by his GP with a three-month history of low energy.
Take a psychiatric history and assess risk.
Actor Instructions
You are Andrew Green, a 29-year-old man working as an IT consultant. For the last three months, you have noticed a deepening sense of sadness that doesn’t lift, even at weekends. You have lost interest in all your usual activities—previously you played football, met friends, and enjoyed gaming online, but now you rarely do any of these things. Most days, you struggle to get out of bed and often call in sick to work, feeling you cannot face the day.
You describe feeling constantly tired and sluggish, even though you are sleeping more than usual. You find it hard to concentrate, sometimes re-reading the same paragraph several times without taking it in. Your appetite is poor and you’ve lost about half a stone in weight since this started.
You feel detached from your friends and family, sometimes ignoring calls or texts because you “can’t cope with talking.” Your self-confidence has dropped—recently you feel you’re letting everyone down, and you worry your manager will soon fire you. You have not used drugs or started drinking more.
If asked about thoughts of self-harm or suicide, you admit there have been times you wished you wouldn’t wake up, and twice you’ve thought about “just ending it,” but you haven’t made any plans or hurt yourself. You say you feel hopeless, but also that you don’t want your parents or sister to be upset.
You live in a flat with your friends and recently had a breakup of a 2 year long relationship – you thought that she was ‘the one’ but she unexpectedly ended the relationship eight months ago and has since found a new partner. You struggle to believe that you will find love again.
You say you’ve never felt like this before and there is no family history of mental illness. You have never had a period of high mood. You have no significant physical health problems, and you take no medication.
If the interviewer is warm and collaborative, you might discuss pressures at work and feeling embarrassed to ask for help. If you feel judged, you may give short answers, saying “I’m fine,” or “I don’t know.”
Feedback for Scenario 1
Knowledge & Clinical Skills
A good candidate will:
Systematically explore the core and additional symptoms of depression (e.g. energy, sleep, appetite, cognition)
Ask about impact on functioning (work, family, social)
Conduct a thorough risk assessment including exploring protective factors
Exclude differentials e.g. bipolar disorder
Communication
A good candidate will:
Build rapport with open questions and reflective listening
Validate difficulties
Sensitively explore risk to self and others
Example phrases:
“You said you sometimes wish you wouldn’t wake up. Have you ever had any thoughts of taking steps to end your life?” … “what has stopped you?”
Scenario 2: Collateral History Taking
Candidate Instructions:
You are working in a community mental health team. You were scheduled to assess Mr. Ethan Foster, a 28-year-old man referred by his GP due to low mood and weight loss. However, Ethan has not attended the appointment. Instead, his older sister, Ms. Sarah Foster has come in his place.
Take a collateral history from Ms. Foster about her brother, Ethan.
Actor Instructions:
You are Ms. Sarah Foster, the 32-year-old sister of Ethan Foster. Ethan was supposed to have his first appointment today, but this morning he said he “couldn’t face it” and asked you to go without him. You are worried about him and grateful for the chance to talk to someone.
Ethan was always outgoing and active, working as a chef and playing football with friends. About eight months ago, he was made redundant when his restaurant closed. Since then, he has become withdrawn and irritable. He spends most days alone in his flat, rarely answers calls, and has stopped seeing friends. He used to love cooking, but now never cooks for himself and mostly eats takeaway or skips meals.
He has lost a noticeable amount of weight – his clothes hang off him, and you estimate at least a stone lost in the last six months. He often looks unkempt and you’ve noticed he sometimes goes days without showering or changing clothes.
Ethan’s mood is “flat” and he seems to have lost interest in everything. He doesn’t watch football anymore and has given up his gym membership. He says he feels exhausted all the time. His sleep is poor—he stays up late watching TV, then wakes up early and can’t get back to sleep, but he stays in bed until noon.
He often says he feels like a “failure” and is a burden to the family. He sometimes says things like “what’s the point?” or “everyone would be better off without me.” You have asked him directly about suicide, and he admitted he sometimes thinks about “just not waking up,” but he has never made any attempts or specific plans.
He has never had mental health problems before. There is no history of eating disorders – he has never been concerned about his weight or body image. He used to drink a few beers at weekends, but not excessively, and does not use drugs. Your mother had postnatal depression, but there is no family history of suicide.
You are very worried about Ethan’s self-neglect and isolation and hope he will agree to accept help.
Feedback for Scenario 2
Knowledge & Clinical Skills
A good candidate will:
Explore the core and additional features of depression as observed by his sister
Ask about possible triggers (e.g. redundancy)
Explore family history
Assess risk as much as able through collateral
Communication
A good candidate will:
Validate the carer’s concerns and distress
Avoid jargon
Summarise and check understanding
Example phrases:
“Has he ever talked about feeling hopeless, or said things that worry you?”
“Has Ethan ever mentioned wanting to hurt himself, or not wanting to be here?”
“What support does Ethan have around him at the moment?”
Authors/Reviewers
Dr Damir Rafi is a psychiatry speciality registrar in forensics, currently working in London.
Dr Sarah Barber is a Psychiatry Registrar, currently taking time out of clinical work to complete a PhD in psychiatric epidemiology.
References and Resources
1. World Health Organization (2022). ICD-11: International classification of diseases (11th revision).
2. National Institute for Health and Care Excellence (NICE). (2009). Depression in adults: recognition and management. NICE guideline [CG90]. Retrieved from https://www.nice.org.uk/guidance/cg90
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
Related Articles:
Mania History Taking: https://psychpanda.com/mania/
OCD History Taking, Risk & Management: https://psychpanda.com/ocd/
Understanding & Assessing Delusions: https://psychpanda.com/delusions/