The majority of patients with MDD present to their family doctor and are diagnosed in primary care. However, depression is generally underdetected and underdiagnosed in this setting. Older adults rarely see mental health specialists, and are therefore at a higher risk of missed diagnosis. Early diagnosis helps ensure early access to treatment, which is important to help improve quality of life.
Such as persistent low mood, anhedonia, feelings of worthlessness, hopelessness, guilt, or suicide
Including impaired attention, memory, executive function
For example sleep disturbance, sexual dysfunction, reduced appetite
Please refer back to 'Subtypes of major depression' in the 'About Major Depressive Disorder' section
An MDD diagnosis is made by a combination of the patient’s detailed clinical history and psychiatric evaluation.
e.g. first-degree relative with depression, a history of child abuse, marital status
(with relevant input from carers, family and friends)
To rule out any underlying medical cause / to identify any contributing factors
Includes using a validated depression diagnostic test such as a rating scale
Given the heterogeneity in signs and symptoms of depression, it is not surprising that a range of different rating scales have been developed.
Rating scales are useful for screening and assessment and also, if used regularly, to monitor the effectiveness of treatment in order to support therapeutic decision making.
|Hamilton Rating Scale (HAMD-17)||A 17-item physician-administered scale that measures severity of depression on a scale of 0–2 or 0–4, with higher scores (≥ 24) indicating severe depression|
A number of modified (short) versions have been published – a literature review published in 2020 determined that structured versions deliver the highest inter-rater and test-retest reliability
|Montgomery-Åsberg Depression Rating Scale (MADRS)|
A 10-item physician-administered scale that rates depressive symptoms on a scale of 0–6, giving a maximum score of 60
|Beck Depression Inventory (BDI)|
A 21-item patient-reported measure of depression severity that rates symptoms on a 0–3 scale, with higher scores (above 10) indicating increased severity
|Patient Health Questionnaire-9 (PHQ-9)|
A 9-item patient-reported rating scale designed as a screening tool for use in primary care
The standard cut-off score for screening to identify possible major depression is 10 or above
Edinburgh Postnatal Depression Scale (EPDS)
|A 10-item patient-reported rating scale used to screen for postpartum / antepartum depression with a maximum score of 30|
Cut-off values of 10 or 13 are most commonly used
Clinical Global Impressions Scale (CGI)
|Two single-item companion measures assessing severity (CGI-S) and improvement (CGI-I) on a 7-point scale. It is designed to be completed in less than a minute by an experienced rater, taking into account all available case details including a patient's history, psychosocial circumstances, symptoms, behavior and ability to function|
|Zung Self-Rating Depression Scale (SDS)||A 20-item patient-reported rating scale to screen for the presence of depressive disorders in adults. The SDS is widely used, particularly in the research context, with suggested cut-off index values between 50 to 55 depending on population|
Major depression (major depressive disorder, MDD) classification is based on either the 2013 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or the International Classification of Diseases, 10th Revision (ICD-10) classification of mental and behavioural disorders. An update to the ICD has been developed (ICD-11), but global uptake and implementation is still underway.
1. Depressed mood most of the day, nearly every day, either self-reported (e.g., feels sad, empty, hopeless) or observed by others (e.g., appears tearful)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
3. Significant weight changes (e.g., ±5% body weight over a month) or change in appetite nearly every day
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day
9. Recurrent thoughts of death or suicidal ideation, or a suicide attempt
BDI, Beck Depression Inventory. CGI, Clinical Global Impressions Scale. DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. EPDS, Edinburgh Postnatal Depression Scale. HAMD-17, Hamilton Depression Rating Scale. MADRS, Montgomery and Asberg Depression Rating Scale. MDD, Major depressive disorder. PHQ-9, Patient Health Questionnaire-9. SAD, Seasonal affective disorder. SDS, Zung Self-Rating Depression Scale.