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Clinical Practice Keywords Depression/Mental health/

Assessment/Comorbidities
Review
Depression This article has been
double-blind peer reviewed

In this article...
● T
 he symptoms and possible causes of depression, including comorbidities
● How depression is diagnosed and categorised, and issues with the process
● Treatments for depression and how relapses can be prevented

Symptoms and causes of depression,

and its diagnosis and management
Key points
Authors Mary Munro is lecturer, mental health nursing, Robert Gordon University
People often have Aberdeen and community mental health nurse (substance misuse), Royal Cornhill
similar symptoms of Hospital Aberdeen; Rosa Milne is community mental health nurse (adult services),
depression, but each Royal Cornhill Hospital Aberdeen.
person’s experience
is unique Abstract Depression is a common condition. It presents differently in each person,
but common symptoms include feelings of hopelessness, loss of interest in things
Common symptoms previously enjoyed, and reduced motivation and energy. Diagnostic tools are available
include feelings of but, as they do not capture all the factors that affect depression, full clinical
hopelessness, loss of assessments are needed. Misdiagnosis is common. Causes of depression may vary
interest in things but may relate to situational, genetic, biological, environmental or psychological
previously enjoyed, factors. It often occurs alongside other mental health conditions or long-term physical
reduced motivation conditions. Treatment options vary, depending on the severity of the episode, and a
and reduced energy stepped-care approach is recommended. Depression can be recurrent, so treatment
should focus on avoiding relapse.
There is no single
cause of depression; Citation Munro M, Milne R (2020) Symptoms and causes of depression, and its
there may be diagnosis and management. Nursing Times [online]; 116: 4, 18-22.
genetic, biological,

D
environmental and
psychological epression is a major public Signs and symptoms
factors health issue in the UK and For any diagnosis of depression, and ide-
worldwide (Norman and Ryrie, ally before treatment options are explored,
Treatment options 2018). It is estimated to affect the severity of an individual’s depression
vary and a stepped- 264 million people globally (GBD 2017 Dis- should be ascertained; this is indicated by
care approach is ease and Injury Incidence and Prevalence their symptoms. Symptoms may vary
recommended Collaborators, 2018), and defined by the between individuals but, generally, they
World Health Organization (2020) as a will encompass feelings of sadness and
Depression is leading cause of disability worldwide and a hopelessness (Lotfaliany et al, 2019).
recurrent, so major contributor to the overall burden of Norman and Ryrie (2018) have said the
treatment needs to disease. WHO (2020) defines depression as signs and symptoms of depression can be
focus on maintaining low mood and loss of enjoyment in things split into two categories: how an indi-
wellness and that were previously enjoyed. vidual feels and how these feelings affect
preventing relapse The human experience involves periods their behaviour.
of low mood or difficulty, but for most people Common feelings associated with
these feelings pass. The difference between a depression include:
low mood and depression is when an indi- l Low mood;
vidual’s feelings consistently interfere with l Sadness;
their daily life over a minimum period of two l Hopelessness;
weeks (Norman and Ryrie, 2018). An episode l Worthlessness;
of depression can vary in duration from l Low self-esteem;
weeks to years, but normally lasts for a min- l Irritability;
imum of several weeks (Mind, 2017). l Anger.

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Box 1. Common signs and depression as: individual’s personal history and family
l D epressed mood; history of depression during a diagnostic
symptoms of depression
l i ncreased fatiguability; assessment (NICE, 2009).
l Feelings of hopelessness l L oss of interest and enjoyment; The Whooley questions for depression
l Loss of interest in things previously l A t least two other symptoms from screening (Box 2) form a commonly used
enjoyed those listed in Box 1. depression diagnostic tool. However, find-
l Reduced motivation Symptoms must be evident but not pre- ings have suggested the tool alone cannot
l Reduced concentration senting to an intense degree. There may be determine whether a person has depres-
l Reduced self-esteem some difficulty continuing with ordinary sion; if they answer yes to one or both ques-
l Reduced or increased appetite work and social activities, but they will not tions, a full clinical assessment is needed
l Reduced libido stop completely. (Bosanquet et al, 2015). The assessment can
l Disturbed sleep be carried out by a GP or, if the patient pre-
l Feelings of helplessness Moderate depression. Christensen et al (2019) sents in secondary care, an assessing nurse
l Reduced energy define moderate depression as: or doctor who is competent to perform a
l Unexplained aches and pains l A low mood; mental health assessment. The assessment
l Anger or irritability l Loss of interest; must evaluate the person’s mental state and
l Changes in cognition l A t least three other symptoms from accompanying functional, interpersonal
l Guilt or worthlessness those listed in Box 1. and social difficulties (NICE, 2009).
l Ideas or acts of self-harm Symptoms are present to a marked Nurses work at the forefront of patient
l Suicidal thoughts degree, and there is difficulty continuing interaction and care. It is, therefore, essen-
with daily activities. tial that they understand depression,
along with its signs, symptoms and clin-
The detrimental effect these feelings Severe depression. DSM-5 categorises severe ical, social and economic impacts to be
have on how an individual behaves in their depression as: able to provide effective person-centred
daily life means that behavioural symp- l F ive or more symptoms during a care. Nurses from all fields can learn to rec-
toms often include a lack of motivation in two-week period; ognise depression and ensure further
personal care, work and relationships. l A change from previous functioning; assessment and interventions are offered.
Most people present with a variety of signs l L ow mood for most of the day, nearly
and symptoms; the most common are every day, as indicated by either: Misdiagnosis
listed in Box 1 (Norman and Ryrie, 2018). ● S  ubjective report by the individual Misdiagnosis of depression is common
that they feel sad, empty or hopeless; (Bostwick, 2012) because several illnesses
Diagnosis l Objective observation made by others have similar symptoms; for example,
Categorisation that the individual appears tearful or hyperthyroidism symptoms include low
Two main classification system manuals irritable, or is expressing suicidal mood, reduced attention span and fatigue.
are used to diagnose depression: thoughts (National Institute for Depression is underdiagnosed in older
l W HO’s (2016) The International Health and Care Excellence, 2009). adults (Rodda et al, 2011) and can be misdi-
Classification of Diseases, 10th Revision agnosed as dementia due to the similarity
(ICD-10); Diagnostic tools in some symptoms, such as increased social
l t he American Psychiatric Association’s Health professionals can use a variety of isolation and mood changes. An assess-
(2013) Diagnostic and Statistical Manual tools to help with accurate and robust ment tool such as the General Practitioner
of Mental Disorders, Fifth Edition diagnosis of depression (Nabbe et al, Assessment Of Cognition (gpcog.com.au)
(DSM-5). 2018). However, NICE (2009) identified may be required to differentiate between
Both manuals categorise depression into that a range of biological, psychological symptoms of depression and dementia.
three main categories – mild, moderate and and social factors can have a significant
severe – depending on the number of symp- impact on depression and are not wholly Possible causes
toms (Table 1), their duration and frequency. captured by diagnostic systems. It is, Depression is a complex condition, and its
Mild depression. The DSM-5 defines mild therefore, vital to consider the causes are not fully understood. Genetics,

Table 1. Overview of the categories of depression

Depression category
Mild Moderate Severe
Feature Two or three common depressive Four or more common depressive Several common depressive
symptoms (Box 1) symptoms (Box 1) symptoms (Box 1), which are
marked and distressing

Presentation ● The individual may display some ● The individual is likely to have ● The individual has marked feelings
distress due to these symptoms, great difficulty continuing with of worthlessness, hopelessness or
but can continue with daily daily activities guilt; difficulty or inability to
activities with little impact continue with daily activities
● Suicidal thoughts and plans

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Box 2. Whooley questions for depression screening l I ncreased economic issues caused by ill
health;
l During the past month, have you often been bothered by feeling down, depressed l G  reater levels of disability;
or hopeless? l A  n increased deterioration in
l During the past month, have you often been bothered by little interest or pleasure functioning than when depression or a
in doing things physical condition is present alone
‘Yes’ to one or both questions = positive test (requires further evaluation) (Kang et al, 2015).
‘No’ to both questions = negative test (individual does not have depression) These findings emphasise the impor-
Source: Whooley et al (1997)
tance of careful psychological assessment
and treatment of people with a long-term
physical condition, even in the critical
biology, environment and psychological for some individuals, and has been linked stages of a disease. Nurses in all fields
factors may play a role, and it can affect to a greater risk of developing depression should consider the mental health of
people of any age, race and socioeconomic as well as other mental health conditions people in their care.
status. Why people experience depression (Esiwe et al, 2015).
varies, so it is important to treat each person Ongoing research suggests that people Comorbidity with mental health
individually and understand their symp- who have experienced adverse childhood conditions
toms and behaviours by getting to know events, trauma or abuse have increased Depression can exist comorbidly with other
them – don’t look at the diagnosis of depres- symptoms of depression compared with mental health conditions, including sub-
sion alone, as the cause will be personal to the general population (Bond, 2019). stance use disorders (Blanco et al, 2013).
individual (Norman and Ryrie, 2018). Depression has also been found to be more Kellner et al (2012) said this was partly
prevalent in people with a lower socio- because people with a substance use disorder
Epidemiology economic status and a lower subjective commonly face stigmatisation, marginalisa-
In the Adult Psychiatric Morbidity Survey social status (Hoebel et al, 2017). There is tion and financial insecurity, which can
undertaken in England in 2014, 3.3% of also evidence suggesting an association cause depressive symptoms. People with a
respondents reported that they were expe- between social deprivation and depres- substance use disorder who have a diagnosis
riencing depression (McManus et al, 2016), sion: Fiske et al (2009) found that people in of depression are at a higher risk of death by
while in Scotland 20% of the adult popula- areas of great deprivation are four times overdose than other substance users (Pabayo
tion experienced one or more symptom of more likely than the general population to et al, 2013). Kellner et al (2012) identified that
depression in 2014/15 (Mental Health Foun- experience depressive symptoms. 50% of people with a substance use disorder
dation, 2016). reported symptoms of severe depression but
Although the exact reasons why depres- Comorbidity with physical conditions were not receiving any treatment for it.
sion manifests are unclear, there are some A number of studies have highlighted the Another common comorbidity of
theories to help our understanding. Almost link between depression and long-term depression is anxiety disorder (Hranov,
all community epidemiological studies physical health conditions, including: 2007). Having both anxiety and depression
find that gender, age and marital status are l A rthritis; has been found to increase the severity and
associated with depression. Kessler and l A sthma; number of symptoms of each condition,
Bromet (2013) have suggested that adult l C ancer; resulting in greater impairment (Hofmeijer-
women are at almost double the risk of l C ardiovascular disease; Sevink et al, 2012). Some of the symptoms of
severe depression compared with men and l D iabetes; anxiety and depression also overlap, for
a study by Van de Velde et al (2010) identified l S troke; example overthinking, avoidance and sleep
that women represented statistically higher l R espiratory illnesses; disturbance (WHO, 2020). The high rate of
rates of severe depression in 15 of the 18 l M usculoskeletal disorders; comorbidity of anxiety and depression sug-
countries they studied. Kessler and Bromet l N eurological disorders (Kang et al, 2015; gests we should consider the occurrence of
(2013) suggested people who are separated Fiske et al, 2009; NICE, 2009). one disorder as a pre-disposing factor for
or divorced have significantly higher rates The life expectancy of people who are developing the other (Cameron, 2007).
of severe depression, compared with those diagnosed with severe depression is
who are married. 10 years lower than that of the general pop- Treatment and support
Some studies suggest that genetics can ulation; one reason for this is the higher Treating depression
influence the risk of developing depres- suicide rate in this group, but it is also NICE (2009) recommended a stepped-care
sion – for example, Elwood et al (2019) have because depression elevates the risk of the approach to treat depression, using a
found that some genes may play a key role onset, persistence and severity of a wide framework that lists the most-effective
in developing recurrent depression. How- range of physical disorders (Norman and interventions (Table 2). In stepped care,
ever, it must be noted that there is no one Ryrie, 2018). Long-term physical condi- the least-intrusive, most-effective inter-
gene linked to depression. tions can also cause or exacerbate depres- vention is provided first; if a person does
Studies have shown that lifestyle sive symptoms (NICE, 2009). This comor- not benefit from it, or declines it, they
choices such as a lack of exercise, being bidity has been attributed to: should be offered an appropriate interven-
underweight or overweight and having l B oth conditions causing a poor quality tion from the next step.
fewer social relationships can increase the of life; Cognitive behavioural therapy, behav-
risk of developing depressive symptoms l T he physical condition progressing, ioural activation methods, self-help
(Esiwe et al, 2015). The use of legal and causing increased depressive symptoms; approaches, interpersonal therapy and
illegal drugs may also be a way of coping l A n increased mortality risk; counselling have all proved effective

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Table 2. Stepped-care approach to treating depression

Step Focus of the intervention Nature of the intervention

1 All known and suspected presentations of Assessment; support; psychoeducation; active monitoring and
depression referral for further assessment and interventions

2 Persistent sub-threshold depressive symptoms; Low-intensity psychosocial interventions; psychological

mild-to-moderate depression interventions; medication; referral for further assessment and
interventions
3 Persistent sub-threshold depressive symptoms or Medication; high-intensity psychological interventions;
mild-to-moderate depression with inadequate combined treatments; collaborative care and referral for further
response to initial interventions; moderate and assessment and interventions
severe depression
4 Severe and complex depression; risk to life; severe Medication; high-intensity psychological interventions; electro-
self-neglect convulsive therapy; crisis service; combined treatments;
multiprofessional and inpatient care

Source: Adapted from NICE (2009)

psychological interventions for depression providing education and information multifaceted, holistic approach to treat-
(Ekers and Webster, 2012). Both technology- to people seeking or receiving mental ment (Loos et al, 2017).
assisted and face-to-face therapy have been health services and their families);
found to be effective (Zhang et al, 2019). l M
 edications management; Avoiding relapse
Electroconvulsive therapy can be used l M
 onitoring. Depression is common and often chronic
for severe depression; despite controversy and recurrent (Uher and Pavlova, 2016). Its
about the treatment, due to misconcep- Providing support symptoms and outcomes are marked by
tions or unfamiliarity, it is acknowledged NICE’s (2009) guidance stated that when persistent suffering, poor overall health
as one of the most-effective treatments for working with people who have depression, and negative effects on several areas of life,
severe mood disorders (Kellner et al, 2012). ‘best practice’ means: including psychosocial, academic and
Newer treatments are being researched l H aving a non-judgemental attitude; work life (de Zwart et al, 2018). One study
and developed for treatment-resistant l P romoting hope and recovery; found that fewer than a third of patients
depression, such as esketamine given by l B eing respectful of privacy and dignity; recovered and remained well in the
oral, intranasal and intravenous routes l S upporting families or carers. 18 months after an episode of depression
(Bozymski et al, 2019). Most first-line anti- NICE (2009) also recognised that (Mulder, 2015). This suggests treatment
depressants take 4-6 weeks to achieve full depression may be accompanied by dis- needs to focus on maintaining wellness
effect; the response time for intravenous crimination and stigma. and preventing relapse.
esketamine is as short as 2-24 hours post- Stigma is a significant issue in mental To help prevent relapse, it is helpful to
administration in clinical trials (Bozymski health: it lowers people’s self-esteem, use the recovery model, a holistic, person-
et al, 2019). Although esketamine could be a makes symptoms more severe and limits centred approach to mental health care
promising option for treatment-resistant help-seeking behaviours (Sastre et al, that is becoming the standard model. It is
depression, its disadvantages include its 2019). Nurses should be aware of the poten- based on two simple premises:
cost, the time commitment required to tial for self-stigmatisation in people with l I t is possible to recover from a mental
receive treatment under supervision of a depression. Forming an effective thera- health condition;
health professional in a clinical setting and peutic alliance has been shown to improve l T  he most-effective recovery is patient
its unpleasant side-effects. According to clinical outcomes in people with depres- directed.
Bozymski et al (2019), adverse effects sion (Arnow et al, 2013) and reduce nega- A significant part of sustained recovery
include dizziness, somnolence, dissocia- tive self-perception (Porr et al, 2012). from depression is being able to avoid or
tion, suicidal thoughts and behaviours, and Community and third-sector support is cope with relapse risk factors (Jumnoodoo et
increased heart rate and blood pressure. also often available. This can include: al, 2017). Recovery can mean a person staying
Treatment and support for depression l P eer support groups; in control of their life and living in a way that
can come from many health professionals l S ocial groups; is meaningful to them, rather than returning
in primary or secondary care, depending l O pportunities for exercise; to the level of functioning they experienced
on the severity of symptoms. Mental l H elp to change to a healthy diet. before depression (Jacob, 2015). Although
health nurses, GPs, occupational thera- These have been shown to improve depression is a chronic condition that can
pists, psychologists and psychiatrists can symptoms (Rosenbaum et al, 2014; Cruwys recur throughout someone’s life (Uher and
all provide evidence-based interventions. et al, 2013; Sanchez-Villegas and Martínez- Pavlova, 2016), this does not have to mean a
Core interventions for nurses working González, 2013; Pfeiffer et al, 2011). state of consistent suffering and powerless-
with people with depression include: A key part of recovering from a mental ness but, instead, a journey that includes set-
l P  sychological approaches; health condition is patient choice; people backs and successes (Scottish Recovery Net-
l P  sycho-education (the process of with depression may benefit from a work, NHS Education for Scotland, 2007).

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Modern-day living and its pressures unrecognised trauma. Healthcare Counselling and study. BMC Psychiatry; 17: 1, 38.
have been linked to a rise in depressive Psychotherapy Journal; 19: 1, 8-13. Lotfaliany M et al (2019) Variation in the
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