Depression: Assessment

Assessment

The assessment of MDD involves the specific identification of five of nine criterion symptoms which would constitute a diagnosis of MDD. A careful general medical assessment to ascertain the pres-ence of an etiologic general medical condition is required. After the assessment for general medical conditions, one examines the individual for the presence of alcohol or drug dependence. Then the clinician is required to assess retrospectively the occurrence of prior episodes of mood disorder, either depression or mania. It is necessary to examine for other comorbid psychiatric disorders as well. Depressive illnesses are very common and recurrent, but an individual with MDD may or may not recall prior episodes. It is therefore essential to interview a significant other in addition to the patient to identify prior manic, hypomanic, or prior depres-sive episodes. Family inquiry allows one to elicit the family his-tory of addiction, anxiety, depressive disorder, mania, psychosis, trauma, or neurologic disorders in first-degree relatives.

To assess risk for suicide, one inquires about the presence of active suicidal ideation in relation to the current episode of de-pression and a history of prior suicide attempts. The occurrence of significant life events such as separation, divorce and death of significant others may precipitate the episode. It is also necessary to review onsets of other medical conditions which may precipi-tate a new episode of depression. When alcohol or other drug use cooccurs with such significant life events, the risk of suicidal be-havior during an episode of depression increases. The presence of a recent suicide attempt may suggest the need for immediate hospitalization and treatment.

General Medical Assessment

The individual who presents for outpatient or hospital treatment for a primary depressive disorder will require general medical examination including a physical examination and laboratory testing to rule out an associated medical condition. Clinical as-sessment, including the cognitive mental status examination, will direct the extent of the general medical examination.

Laboratory studies in the management of the individual with MDD includes complete blood count with differential, elec-trolytes, chemical screening for renal and liver function, as well as thyroid function studies. More detailed evaluation will depend upon the nature of the clinical presentation as well as neuropsy-chological examination. These studies may identify cerebral vul-nerability factors that would complicate the treatment for MDD.

When clinical signs suggest cognitive disruption or cogni-tive impairment, the clinician may also consider administering neuropsychological tests or conducting more focused neurologic examination to explore cognitive, behavioral and neurologic cor-relates of brain function. Neuropsychological assessment may help to clarify the relative contribution of depression or another disease process to the patient’s clinical presentation. Further, neu-ropsychological assessment will provide a functional analysis of the patient’s cognitive and behavioral strengths and limitations. Neurological examination may reveal minor neurological abnor-malities suggesting early neurodevelopmental vulnerability.

Psychodiagnostic Assessment

Traditional psychological testing may complement structured diagnostic instruments developed to ascertain the presence or absence of depressive disorders according to DSM-IV criteria. Psychological testing such as the Rorschach Inkblot Test are sen-sitive to the degree of affective lability, intensity of suicidality and impulse control in individuals with depression. In addition, in-ventories are commonly used in outpatient and inpatient settingsto establish scores of clinical severity of depressive symptoms. Self-administered scales include the Beck Depression Inventory, the Zung Self-Rating Depression Scale and the Inventory for Depressive Symptomatology (self-report). Psychiatrist-adminis-tered scales used for assessment of depressive symptoms include the Hamilton Rating Scale for Depression, the Montgomery Asberg Depression Rating Scale and the Inventory for Depres-sive Symptomatology (psychiatrist rated). Structured diagnostic interviews that have been developed to confirm major psychiatric syndromes include the present state examination, the schedule for affective disorders and schizophrenia (SADS) and structured clinical interview for DSM-IV Axis I disorders (SCID-I). The use of these structured diagnostic interviews reliably predicts the presence of an MDD. It is essential to recognize that a cross-sec-tional assessment is only one component of the total assessment. Corroborative family data and longitudinal assessment and reas-sessment of mood disorder symptoms are crucial in following the natural history and course of MDD.