MDD

1. CPG Major Depressive Disorder
2007
Assessment & Diagnosis
Dr Nurulwafa Hussain
Pakar Psikiatri Kanak-kanak & Remaja
Hospital Melaka

2. Objectives
By the end of this unit, you should be able to:
• Screen for depression
• Elicit the symptoms of depression
• Make a diagnosis of major depressive disorder
• Assess the severity of major depressive
disorder
• Assess suicide risk

6. Assessment
• History taking
• Relevant medical history/ substance use
• Mental state examination
• Physical examination
• Laboratory investigation

8. Screening for Depression
Two questions may be used to screen for
depression
• 1. “During the past month, have you often
been bothered by feeling down, depressed or
hopeless?”
• 2. “During the past month, have you often been
bothered by having little interest or pleasure in
doing things ?”
A “Yes” response to either or both questions
should prompt you to assess the patient for
depression

9. Interview technique
Observe the following when interviewing
patient:
• Put the patient at ease
• Establish rapport with the patient
• Use open-ended questions as much as
possible
• Clarify patient’s use of medical terms

10. • Convey empathy
• Use facilitation techniques to elicit
information (verbal and non verbal)
• Provide feedback – summarizing history to
recheck accuracy of information
• Re-direct (interrupt) patient tactfully if
necessary, to avoid irrelevant details

11. Interviewing informants
• Patients should usually be interviewed alone
first, before seeing any informants
• But if patient requests it, he can be seen
together with the informant

12. Diagnosis & Assessment
b)Eliciting the symptoms of depression
- History taking / interview technique
- Use DSM 5/ ICD 10 criteria

13. ICD 10

14. ICD 10
• Mild depressive episode
• Moderate depressive episode
• Severe depressive episode without psychotic
symptoms
• Severe depressive episode with psychotic
symptoms

15. ICD-10 criteria
• Typical symptoms of depressive
episode
Depressed mood
Loss of interest & enjoyment
Reduced energy

16. ICD-10 criteria contd…
Common symptoms of depressive episodes
Reduced concentration & attention
Reduced self-esteem & self –
confidence
Ideas of guilt & unworthiness
Bleak & pessimistic views of the future
Ideas or acts of self-harm or suicide
Disturbed sleep
Diminished appetite

17. ICD-10 criteria contd..
• Mild Depressive Episode
At least 2 typical symptoms + 2 common
symptoms
No symptom should be present to an intense
degree
Minimum duration of whole episode is at least
2 weeks
The person has some difficulty in continuing
ordinary work & activities.

18. ICD-10 criteria contd..
• Moderate depressive episode
At least 2 typical symptoms + 3 common
symptoms
Some symptoms may be present to a marked
degree
Minimum duration of whole episode is at least
2 weeks
The person has considerable difficulty in
continuing social, work or domestic activities.

19. ICD-10 criteria contd..
• Severe depressive episode without psychotic
symptoms
All 3 typical symptoms + at least 4 common
symptoms
Some of the symptoms are of severe intensity
Minimum duration of whole episode is at least
2 weeks ( may be <2 weeks if symptoms are
very severe & of very rapid onset.
The person is very unlikely to continue with
social, work or domestic activities.

20. ICD-10 criteria contd..
• Severe depressive episode with psychotic
symptoms
A severe depressive episode
Delusions, hallucinations or depressive stupor
are present.

21. DSM 5

22. DSM 5
Symptoms of depression
1. Persistent depressed mood
2. Persistent and marked diminished interest or pleasure in
most activities
3. Significant weight loss or weight gain or changes in
appetite
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive / inappropriate
guilt
8. Reduced ability to think or concentrate or indecisiveness
9. Recurrent thoughts of death, or recurrent suicidal
ideation with or without a specific plan / attempt

23. DSM 5 contd….
Diagnosis of Major Depressive Episode
a) At least 5 of the above symptoms during the
same 2 weeks period & represent a change
from previous functioning :at least one of
the symptoms is either
• depressed mood or
• loss of interest or pleasure

24. DSM 5 contd….
b) The symptoms cause clinically significant distress
or impairment in social, occupational or other
important areas of functioning
c) The episode is not attributable to the
physiological effects of a substance or to another
medical condition

25. DSM 5 contd….
d) The occurrence of the major depressive
episode is not better explained by
schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder
or other specified and unspecified
schizophrenia spectrum and other psychotic
disorders.
e)There has never been a manic episode or a
hypomanic episode

26. DSM 5 contd….
Assessing the severity of Major Depressive episode
• Mild
 Few symptoms in excess of those required to
make the diagnosis ( 5 or 6 symptoms )
 Only minor impairment in occupational & social
functioning .
• Moderate
 Symptoms markedly interfere with occupational
& social functioning

27. DSM 5 contd….
• Severe without psychotic symptoms :
Several symptoms in excess of those required
to make the diagnosis ( 8 or 9 symptoms )
Symptoms markedly interfere with
occupational & social functioning.
 Severe with psychotic symptoms :
Delusion or hallucinations

28. ASSESSING SUICIDE RISK

29. Assessing suicide risk
Use the following questions to help you assess
suicide risk :
i) Sometimes when people are facing
difficulties or are distressed, they think that
life is too difficult or they are better off dead.
What about you?
ii) Have you ever tried to harm yourself ?

30. Severity of suicide ideation may range
from:
• thoughts about death in general
• thoughts about one’s own death
• thoughts about ending one’s life
• suicidal plans
• suicide attempts
• completed suicide

31. Referral to Psychiatric Services
Unsure of diagnosis
Attempted suicide
Active suicidal ideas/plans
Failure to respond to treatment
Advice on further treatment
Clinical deterioration
Recurrent episode within 1 year
Psychotic symptoms
Severe agitation
Self neglect

32. Common criteria for admission include:
• Risk of harm to self
• Psychotic symptoms
• Inability to care for self
• Lack of impulse control
• Danger to others

33. Illustrative Case 1
 42 year-old lady, a civil servant, recently divorced
with 4 children.
 She complains of feeling sad, crying spells,
reduced appetite and sleep difficulties for 3
weeks. She has lost 5 kg weight in a month, and
she no longer enjoys doing the things that she
used to do. Her concentration is reduced and her
work is affected with frequent medical leave and
absences from work, and her immediate superior
has cautioned her about the quality of her work.
She has been going to the clinic for complaints of
headache and generalised malaise.

34. Illustrative Case 1 contd…
• A friend informed her one month ago that her husband
was having an affair with another woman. She
confronted her husband and this resulted in him
divorcing her with `talak satu’.
• She had a history of overdosing on 20 tablets of
paracetamol 2 years ago after she found out that her
husband had been having an affair with his secretary.
She thinks more about death and does not believe she
has much of a future, but has not considered ending
her own life.
• All her children are in institutions of higher learning
and boarding school. There is no one else at home
except for the maid.

35. Questions
• What psychiatric diagnosis can you make
for this person ?
• Assess her risk for suicide
(low, moderate, high)

36. Slides Compiled by Pn Chai Chin Chin and
edited by the Training Module Committee
THANK YOU