Brief Treatment Strategies for Major Depressive Disorder: Advice for the Primary Care Clinician

Ivan Valdivia, PhD Candidate; Nadine Rossy, BAC, PhD Candidate


Topics in Advanced Practice Nursing eJournal. 2004;4(1) 

In This Article

Assessment and Monitoring

The assessment and monitoring of MDD are 2 related but separate endeavors, each requiring its own set of clinical tools. A full and proper diagnosis can only be made by interviewing the patient via unstructured, semistructured, or fully structured clinical interviews. It is important to note that a diagnosis cannot be done via self-report measures alone, as they are only intended to be used as screening tools or for monitoring changes in cognition, affect, or mood.[6]

Examples of common semistructured clinical interviews include the Structured Clinical Interview for the DSM-IV-TR, Axis I (SCID-I)[7] and the Mini International Neuropsychiatric Interview (MINI)[8] for adults, and the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS)[9] for children and adolescents. These instruments can be used without cost in research and not-for-profit centers. The symptoms of MDD, and examples of questions to assess the symptoms, can be found in Table 1 .

In making a diagnosis of MDD, it is essential to assess the persistence and duration of the symptoms experienced. Persistence in this context refers to the continuous experience of a symptom, nearly every day. Duration refers to the length of time that the symptom has persisted. In the case of MDD, symptoms must be present all day, almost every day, for at least 2 consecutive weeks. In order to qualify for a diagnosis of MDD, there are 6 steps on the decision tree[3]:

  1. The presence of either sad mood (or irritability in the case of children) and/or anhedonia (ie, a loss of interest or pleasure in almost all things). If neither is present, there is no current major depression. If one or more is present, move to step 2.

  2. The presence of a number of the following symptoms (which, when added to either 1 or 2 of the symptoms from step 1, equal 5 or more symptoms in total): appetite loss/increase or weight loss/gain, insomnia/hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or excessive/inappropriate guilt, difficulty thinking/concentrating or diminished ability to make everyday decisions, and recurrent thoughts or fantasies of death. If the patient has at least 1 or more symptom(s) from step 1 and the total number of symptoms from steps 1 and 2 are greater than 5, move to step 3.

  3. The symptom cluster must have caused clinically significant distress and/or a significant decline in functioning. Areas of functional loss may include: occupation/school, friends and family, and responsibilities at home. If yes, move to step 4.

  4. Exclude diagnosis of MDD if symptoms are due to a physical illness, substance use, or prescribed medications. If not, proceed to step 5. It is important to note that major depression can coexist with medical symptoms and still needs to be addressed and treated.

  5. Exclude the diagnosis if the symptoms are associated with the loss of a loved one within the last 2 months. Do not consider this simple bereavement if there is morbid preoccupation with death or feeling of worthlessness, a marked decline in functioning, suicidal ideation, psychotic symptoms, or psychomotor retardation. If not excluded, move to step 6.

  6. Exclude the diagnosis if there are prominent delusions or hallucinations experienced in the absence of the mood symptoms. Consider a psychotic spectrum disorder. This requires appropriate assessment and treatment but is beyond the scope of this article. A referral to a psychologist or psychiatrist would be necessary in this case.

When assessing MDD, it is important to consider the culture or origin of the individual because MDD can present differently depending on the specific culture. This concern extends to the treatment phase as well.[10]

Monitoring tools differ from diagnostic tools in structure and function; they are tools that are used to assess progress made during and after a course of treatment. Usually a self-report measure will suffice for this purpose. Examples of self-report measures for depression include the Beck Depression Inventory-II (BDI-2),[11] the Zung Self-Rating Depression Scale,[12] and the Centre for Epidemiological Studies Depression Scale available at[13] It is important to remember that a clinician cannot solely rely upon these assessment tools to monitor symptoms and progress. They are only aids and adjuncts to continuous clinical assessment of symptoms throughout the treatment.


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