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Depression - Initial Diagnosis
Overview
Lacking a reliable laboratory test or universally applicable approach to evaluation, the diagnosis of depressive disorders is defined by somewhat complex criteria. These are helpful for describing the various types of depression and for guiding treatment and understanding expected courses and outcomes.Pearls And Alerts
The combination of either depressed mood or diminished interest in usual activities with 5 of the following symptoms fulfills symptom criteria for major depression.
- S - Sleep change
- I - low Interest
- G - Guilt, worthlessness
- E - low Energy
- C - poor Concentration
- A - Appetite change
- P - Psychomotor slowing or agitation
- S - Suicidal thoughts or gestures
St. John's Wort (hypericum), an herbal remedy sometimes recommended for depression, induces Cytochrome P450 3A4 which can result in lowered blood levels of other drugs that are metabolized by that enzyme (e.g., macrolide antibiotics, azole antifungals, benzodiazepines, calcium channel blockers, and calcineurin inhibitors, like cyclosporin and tacrolimus). St. John's Wort also interacts with SSRI (e.g., fluoxetine, sertraline) and SNRI (e.g., venlafaxine) antidepressants. If taken along with these antidepressants, it may increase the risk of serotonin syndrome, a serious and potentially fatal drug reaction.
Practice Guidelines
Birmaher B, Brent D, Bernet W, Bukstein O, Walter H, Benson RS, Chrisman A, Farchione T, Greenhill L, Hamilton J, Keable H,
Kinlan J, Schoettle U, Stock S, Ptakowski KK, Medicus J.
Practice parameter for the assessment and treatment of children and adolescents with depressive disorders.
J Am Acad Child Adolesc Psychiatry.
2007;46(11):1503-26.
PubMed abstract
Differential Diagnosis
A broad array of psychiatric disorders share symptoms with depressive disorders and must be distinguished from depressive disorders during evaluation.Bipolar disorder may present with depressive symptoms. ALL of the symptoms of depression can be present in patients with bipolar disorder, in which patients alternate between depression and elevated mood states known as mania or hypomania. Diagnostic criteria for bipolar disorder in adults are well established but there is controversy over their application in children and adolescents, suggesting referral to a child and adolescent psychiatrist for diagnostic confirmation is appropriate.
Anxiety disorders may present with low self esteem, worthlessness, apparent lack of motivation (often anxiety-based avoidance rather than low motivation), sleep disturbance (insomnia is common as the patient lies awake worrying), eating problems (decreased appetite or eating rituals), poor concentration. Eliciting specific mood symptoms (sadness, irritability) is important in differentiating these diagnoses.
Disruptive behavior disorders/ADHD may present with low self esteem and worthlessness due to social and academic difficulties, as well as poor concentration.
Substance use disorders often present with depressed or irritable mood. Timing of symptom onset is important because of the comorbidity between depressive disorders and substance abuse disorders. If history indicates that mood was normal prior to onset of substance use (and especially if mood returns to normal after use is discontinued), then the mood problem may be secondary to substance use.
Anorexia nervosa often presents with depressed or irritable mood, low motivation, and low energy, in addition to decreased food intake and weight loss.
Medical illness, such as cancer, hematologic disorders, endocrine disorders, immunologic disorders, and infectious diseases (especially HIV), may present with depressive symptoms. "Vegetative symptoms," such as low energy, psychomotor retardation, sleep disturbance, and appetite disturbance, are more common in medical illnesses that mimic depression. Presence of prominent guilt, worthlessness, or suicidal thoughts or behavior suggest comorbid depression. Consider depression when depressive symptoms pre-date diagnosis of the medical illness or arise in a chronically ill patient when other aspects of the illness are stable or improving.
Adjustment disorder with depressed mood consists of depressed mood and impaired function within 3 months of a clearly defined stressful life event. To be diagnosed with an adjustment disorder, the patient cannot meet full criteria for a major depressive episode.
History And Examination
Family History
Family history is helpful in evaluation – depressive disorders have a well-demonstrated genetic component. A full psychiatric family history should include family history of depression, suicide or suicide attempts, psychiatric hospitalizations, bipolar disorder, anxiety disorders, substance use disorders, ADHD, learning disorders, and schizophrenia.Pregnancy/Perinatal History
There is growing interest in the relationship of perinatal factors, such as low birth weight, with depression in later life but conclusive data is lacking.Medical History
The history should address symptoms of depression that overlap with those of medical illness (e.g., insomnia, hypersomnia, low energy, appetite changes, and weight changes) and symptoms that might indicate an underlying medical cause for depression.An up-to-date history of medication use and current medications (including herbal medications [particularly St. John's Wort – see Alert], dietary supplements, and OTC medications) is important, especially if medication therapy for depression is a consideration.
Developmental and Educational History
Always consider the child's developmental level when looking for behaviors and changes in mood that might signal a depressive disorder.Children and adolescents with developmental delays can also develop depression. The term "dual diagnosis" refers to the combination of intellectual disability/mental retardation and a psychiatric disorder in the same patient.
See the Related Issue Depression Through Childhood Development for more detail.
Physical Exam
General
A normal physical exam can help to rule out medical illness as a cause for depressive symptoms. Examination is also helpful to address the multiple physical complaints (e.g. abdominal pain) which often accompany depression. If a patient presents with concerns of depression, has had a recent physical exam (within the past 6-12 months), and has no new physical complaints or illnesses on review of systems, the physical exam may be deferred at the clinician's discretion to allow more time for interviewing.Testing
Laboratory Testing
Tests to consider in evaluation for a depressive disorder include TSH to screen for hypothyroidism and urine drug screen to screen for substance use, which may be complicating or causing the depression. A urine pregnancy test should be considered in females to allow for consideration of pregnancy in treatment decisions.Subspecialist Collaborations and Other Resources
Patients currently expressing active suicidal ideation or who have recently made a suicide attempt should be referred for inpatient psychiatric hospitalization.
Child Psychiatry (see Services below for relevant providers)
May aid in diagnosing and/or providing continuing care. Due to chronic shortages in the US, these subspecialists often primarily see patients with the most severe mental illnesses or those with complicating biological, psychological, or social factors. Consider referral for depression for patients who:
- Have no improvement after 6 to 8 weeks of medications or therapy
- Require more than two psychotropic medications to control symptoms
- Require psychiatric hospitalization
- Have parents with significant emotional impairment or substance use issues
- Have complex psychosocial issues (e.g. history of abuse/neglect, legal problems, poor parental support/supervision, family conflict)
- Have family history suggesting adverse reactions to therapy (e.g. planned antidepressant therapy in a patient with family history of bipolar disorder)
- Are young (6 years or under)
- Have chronic medical illness
See also AACAP Guidelines: When to Seek Referral or Consultation with a Child and Adolescent Psychiatrist.
Referral is necessary for patients with suspected bipolar disorder or depression with psychotic features.
Child Psychology (see Services below for relevant providers)
A clinical child psychologist will have a PhD or PsyD. Individuals with bachelors or masters degrees in psychology are generally not trained or qualified to diagnose or treat mental illness. All states have licensing requirements for psychologists. Psychologists may be trained in various fields – clinical psychologists or counseling psychologists are the most apt to evaluate or treat depression. Psychologists may perform diagnostic interviewing or specific testing, such as intelligence or personality testing. Psychologists may provide psychotherapy but are not generally trained nor permitted to prescribe medications (although two states, Louisiana and New Mexico, allow clinical psychologists with special training to prescribe some medications). Many psychologists will, however, consult with prescribers, such as physicians, to help coordinate diagnosis and treatment.
Social Work (see Services below for relevant providers)
There are varying levels of academic degrees and fields of expertise in Social Work. All states have specific licensing requirements for social workers. Independently practicing social workers or those working in a hospital or healthcare setting should have a minimum of a master’s degree. Mental Health and Substance Abuse Social Workers are the most apt to be involved in evaluating or treating depression. Social workers may interview for assessment but usually are not qualified to make a formal mental health diagnosis. Social workers may provide psychotherapy and may consult with other specialists to coordinate treatment.
Counseling (see Services below for relevant providers)
Aside from psychologists, and social workers, there are a number of disciplines that may provide psychotherapy. Most often, these counselors hold a masters degree in Clinical Mental Health Counseling, Marriage and Family Therapy, or Substance Abuse and Behavior Counseling. Counselors, like social workers, may do interviewing for assessment purposes but they usually are not qualified to make a formal mental health diagnosis. Most states have specific licensing requirements for governing counselors in practice.
Resources
Information & Support
For Professionals
Depression Resource Center (AACAP)
Information for clinicians and families, including FAQs, information on brochures (“Facts for Families”), books, videos, practice
parameters, research, and getting help for depression; from the American Academy of Child & Adolescent Psychiatry.
For Parents and Patients
Support
NAMI Utah
Utah Chapter of the National Alliance on Mental Illness; provides advocacy, and information about mental illnesses.
National Alliance on Mental Illness
Provides information about mental illnesses, links to state chapters, information about conferences, and links to additional
resources.
Practice Guidelines
Birmaher B, Brent D, Bernet W, Bukstein O, Walter H, Benson RS, Chrisman A, Farchione T, Greenhill L, Hamilton J, Keable H,
Kinlan J, Schoettle U, Stock S, Ptakowski KK, Medicus J.
Practice parameter for the assessment and treatment of children and adolescents with depressive disorders.
J Am Acad Child Adolesc Psychiatry.
2007;46(11):1503-26.
PubMed abstract
The most recent practice parameter on the diagnosis and treatment of depressive disorders in children and adolescents.
Tools
Depression Scale for Children (Bright Futures)
(
37 KB)
free depression screening tool for ages 12-18 (Center for Epidemiologic Studies - Depression Scale for Children); 6th grade
reading level; 20 items; 5-10 minutes to complete.
Beck Depression Inventory-II (Pearson Assessments)
ages 14 and older; 6th grade reading level, Spanish version available; 21 items, 5 to 10 minutes to complete.
Depression Tool Kit (MacArthur Foundation Initiative on Depression and Primary Care)
Designed for primary care practices to help in the diagnosis and management of maternal depression; contains screening tools,
patient handouts, medication information, resources, and references and includes the 9-question Public Health Questionnaire
(PHQ-9). Available for download upon agreement to terms.
Patient Health Questionnaire 9
This is a validated, quick, and free screening tool for depression to be used by primary care providers.
Services
For other services related to this condition, browse our Services categories or search our database.