REVIEW ARTICLE

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DEPRESSION IN PRIMARY CARE
PART 1: SCREENING AND DIAGNOSIS

SCREENING FOR DEPRESSION

Clinical interviews are important in assessing depression. A good interview will retrieve information for further action and at the same time establishes a good doctor-patient relationship.¹⁸ The assessment must include finding symptoms to diagnose depression and the impact it has on the patient’s life.

Screening questions for depression⁹ include:

1. How have you been feeling recently?
2. Have you been low in spirits?
3. Have you been able to enjoy the things you usually enjoy?
4. Have you had your usual level of energy, or have you been feeling tired?
5. How has your sleep been?
6. Have you been able to concentrate on newspaper articles or television or radio programmes?

The final step would be focusing on the patient’s personality and excluding other conditions which may affect the outcome. Some cases may not be clear-cut. Perhaps a few specific questions at the end of the interview may help further clarify the diagnosis of depression18 such as:

1. Do you have any trouble with your nerves, sleep or appetite?
2. Does your mood fluctuate during the day?
3. Do you still gain enjoyment from life?
4. Do you still take an interest in everyday events?
5. Are you inclined to ruminate?
6. Do you find it difficult to make decisions?

Another simple way to assess would be a careful inquiry into the mnemonic SIGECAPS – Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor Function and Suicide.19 Symptoms such as poor sleep, low energy or poor appetite are non-specific as they can be seen in patients with underlying medical problems. Therefore, any positive answer should be probed further. If depression is confirmed or suspected, further assessment of suicide risk must be made. The expression of a ‘wish to die’ is the best indicator of high suicide risk. Other indicators include previous attempts, family history of suicide, a suicide plan, recent attempts and leaving a suicide note or if it was carefully prepared with precautions against discovery and/or highly lethal. In addition, other factors that increases the risks include older age, male gender, unemployment, social isolation and chronic medical illnesses.

Apart from questioning, rating scales can be used to screen for depression. Table 2 summarizes the different types of questionnaires that are easy to administer in primary care clinics.

Table 2. Screening tools for depression

Tools	Address22	Rating / Purpose	Population
Patient Health Questionnaire (PHQ)20 PHQ is a trademark of Pfizer Inc. www.pfizer.com/phq-9	Dr Robert L. Spitzer Columbia University, 1051 Riverside Drive, Unit 60, NYS Psychiatric Institute, New York, NY 10032, USA	Self-report. To screen for depression in primary care.	Adults and adolescents
Hamilton Depression Rating Scale (HDRS or Ham-D)24 See Appendix	Public Domain	Clinician rated. To assess severity of depression and change in symptoms.	Adults
Geriatric Depression Scale (GDS)26	Dr Jerome Yesavage Stanford University School of Medicine Stanford, CA 94305-5548, USA	Self report. To assess depression in older adults.	People aged ≥ 65 years