Quality statement 1: Assessment
Recognition of suspected depression is based on clinical suspicion or responses to questions used to initially identify depression. A comprehensive assessment includes discussion of factors affecting the development, course and severity of depression and enables confirmation of a diagnosis of depression. The assessment may also identify other mental health conditions that share similar symptoms, such as bipolar disorder and post-traumatic stress disorder. If the adult has additional needs affecting language and communication, these should be identified and the assessment adjusted to enable participation. Establishing a diagnosis of depression is an essential first step in the care of adults with depression, leading to appropriate treatment at the earliest opportunity.
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Proportion of adults with a new episode of depression who had a comprehensive assessment before receiving a diagnosis.
Numerator – the number in the denominator who had a comprehensive assessment before receiving a diagnosis.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
The proportion of adults diagnosed with depression who reported satisfaction with their assessment.
Numerator – the number in the denominator who reported satisfaction with their assessment.
Denominator – the number of adults diagnosed with depression who had an assessment.
Data source: NHS England's Improving Access to Psychological Therapies (IAPT) collects data on satisfaction with assessments delivered in IAPT services. Annual results are presented at national, commissioning and provider levels. The Care Quality Commission's NHS community mental health survey contains the question: 'did the person or people you saw understand how your mental health needs affect other areas of your life?'
Service providers (such as GP practices, NHS talking therapy services and NHS acute and mental health trusts) ensure that protocols are in place for adults with suspected depression to have a comprehensive assessment, which includes discussion of factors that may have influenced the development of their depression.
Healthcare professionals (such as GPs, nurse practitioners, specialist nurses, therapists in NHS talking therapy services and mental health professionals) carry out a comprehensive assessment if they suspect depression (based on clinical suspicion or responses to questions used to initially identify depression). This assessment includes discussion of factors that may have influenced the development of the adult's depression. If they think they do not have the competence to carry out a mental health assessment, they refer adults with a new episode of depression to a healthcare professional who does.
Commissioners ensure that they commission services in which adults with suspected depression based on clinical suspicion have a comprehensive assessment, which includes discussion of factors that may have influenced the development of their depression.
Adults with suspected depression have an assessment during which they discuss factors that may have contributed to their depression with a healthcare professional. The aim of the assessment is to confirm a diagnosis of depression.
Depression in adults: treatment and management. NICE guideline NG222 (2022), recommendations 1.2.6 and 1.2.7
Depression in adults with a chronic physical health problem: recognition and management. NICE guideline CG91 (2009), recommendations 126.96.36.199 and 188.8.131.52
A healthcare professional suspects that an adult has depression based on clinical judgement or if the adult answers 'yes' to either of the following questions used to initially identify depression:
During the last month, have you 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?
[Adapted from NICE's guideline on depression in adults, recommendations 1.2.1 to 1.2.3 and terms used in this guideline; NICE's guideline on depression in adults with a chronic physical health problem, recommendation 184.108.40.206; and expert opinion]
A first or subsequent episode of depression. [NICE's guideline on depression in adults, definitions of depression and severity]
A comprehensive assessment should include:
severity of symptoms
previous history, duration and course of illness
degree of functional impairment or disability, or both.
The assessment should include discussion of how the following factors may have affected the development, course and severity of their depression:
any history of depression and coexisting mental health or physical disorders
any history of mood elevation (to determine if depression may be part of bipolar disorder; see the NICE guideline on bipolar disorder)
any past experience of, and response to, previous treatments
personal strengths and resources, including supportive relationships
difficulties with previous and current interpersonal relationships
current lifestyle (for example, diet, physical activity and sleep)
any ongoing, recent or past experience of stressful or traumatic life events, such as early adversity (including physical abuse, sexual abuse or bullying), redundancy, divorce, bereavement, or trauma (see the NICE guideline on post-traumatic stress disorder)
living conditions, drug (prescribed or illicit) and alcohol use, debt, employment situation, loneliness and social isolation.
To improve the accuracy of the assessment for adults with a physical health problem with a new episode of depression, a healthcare professional should also:
Healthcare professionals should be aware that symptoms of depression may overlap with symptoms of, for example, learning disabilities, other existing or new mental health conditions, physical health conditions, or menopause. [Adapted from NICE's guideline on depression in adults, recommendations 1.2.2, 1.2.3, 1.2.6 and 1.2.7; NICE's guideline on depression in adults with a chronic physical health problem, recommendations 220.127.116.11 and 18.104.22.168; and expert opinion]
Some adults may need additional support during assessments of depression, including:
Examples of adapting assessments include:
using a method of communication appropriate for their needs (for example, using a British Sign Language interpreter, or augmentative and alternative communication)
using interpreters from the same cultural background
using language that takes into account family background and wider context.
Commissioners and providers should consider their local population and any unwarranted variation in prevalence of depression between adults in groups such as:
adults from minority ethnic backgrounds
lesbian, gay, bisexual and trans adults
adults experiencing homelessness, refugees and asylum seekers.
[Adapted from NICE's guideline on depression in adults, recommendations 1.2.5, 1.2.14, 1.16.5 and 1.16.6 and information for the public, and NICE's guideline on depression in adults with a chronic physical health problem, recommendation 22.214.171.124]