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Synthesized Answer Setting D2

How should depression be diagnosed?

(All information below is drawn from NG222 "Depression in adults: recognition and management".)

1. General approach to recognition and assessment

• Be alert to possible depression in people with past depression or a chronic physical health problem associated with functional impairment.
• Consider asking the "Whooley" or 2-item questions (see section 2) in people with significant physical illness causing impairment, or other risk factors.
• If the person scores positively on either Whooley question, or if clinical suspicion remains, follow up with a comprehensive assessment (see section 3).
• Do not use brief assessment tools to exclude depression.
• Base diagnosis on a full clinical evaluation, not on questionnaire scores alone.
• Use validated symptom measures (PHQ-9, HADS-D, BDI-II) only to inform the severity assessment and to monitor progress after a diagnosis has been made.

2. Initial brief questions (Whooley questions)

Ask the two questions below. A positive response to either indicates the need for further assessment:

"During the last month, have you often been bothered by feeling down, depressed or hopeless?"

"During the last month, have you often been bothered by having little interest or pleasure in doing things?"

3. Comprehensive assessment (after positive screen or high clinical suspicion)

Core domains to cover

• Full history of mood and associated symptoms, duration, severity, fluctuation, previous episodes, response to past treatments.
• Functional impact on work, relationships, activities of daily living.
• Alcohol or substance use.
• Co-existing physical health problems or medications that may contribute.
• Psychosocial stressors and social support.
• Risk of suicide or self-harm.
• Personal and family psychiatric history.
• Patient preferences and priorities for treatment.

Special populations

• People with a chronic physical health problem: integrate assessment with management of that condition [NG222:1.2.13].
• People with a diagnosis of personality disorder: follow recommendations in NG222 section 1.11 [NG222:1.11.3].

4. Severity classification (used to guide treatment choice)

After confirming a depressive episode, categorise severity using ICD-10 symptom counting plus functional impairment:

• Less severe depression - fewer than 5 ICD-10 symptoms, or 5 symptoms with only mild functional impairment.
• More severe depression - 5 or more ICD-10 symptoms with at least moderate impairment.

Validated tools (PHQ-9, HADS-D, BDI-II) can support, but not replace, this classification.

5. Documentation and communication

• Record the severity classification, key symptoms, functional impact, and comorbidities clearly in the notes.
• Share the diagnosis and severity explanation with the person in accessible language.
• Provide written or digital resources about depression and available treatments.

6. Next steps after diagnosis

• Discuss all suitable treatment options (low-intensity psychological, high-intensity psychological, pharmacological, combined) aligned with severity and patient preference.
• Arrange follow-up to review effectiveness, side effects, and adherence; adjust the care plan as needed.