Description
Depression is a common mental disorder that typically presents with a range of symptoms and varying levels of impairment in social and occupational functioning.
ICD 10 Diagnostic Criteria:
Depression is defined as the presence of pervasive low mood and a loss of interest and enjoyment in activities, occurring most of the day, nearly every day, for at least 2 weeks, as well as other symptoms such as:
- Reduced concentration and attention
- Reduced energy or fatigue
- Ideas of guilt or unworthiness
- Bleak and pessimistic views of the future
- Ideas or acts of deliberate self harm or suicide
- Disturbed sleep
- Significant changes in appetite or weight
- Psychomotor agitation or retardation.
Assessment also includes consideration of onset, duration, pattern and severity of symptoms, as well as impact on functioning, risk of self-harm and suicide.
Depressive episodes are subdivided into less severe (encompassing subthreshold and mild depression) and more severe (encompassing moderate and severe depression).
Treatment
Initial support should include psychoeducation (this link can be shared with patients) and activities that could improve the person’s sense of wellbeing. Treatment should take a shared decision-making approach and follows a matched care model.
Consideration should be given to situational factors such as housing, financial, occupational, social or relationship instability or difficulties that might benefit from an alternative approach through third sector organisations (e.g. Citizen’s Advice Bureau, relationship counselling, Women’s Aid).
For less severe depressive episodes, which can be driven by situational stress, lower intensity options include:
- Active monitoring
- Silvercloud (computerised Cognitive Behavioural Therapy, referral via Sci Gateway)
- Physical activity for mental health referrals
- Psychoeducation, including Stress Control classes, where available (self-referral)
- Guided self-help offers a short series of supportive sessions to work through CBT-based self-help materials. These are usually available on a self-referral basis.
- In Edinburgh, iThrive and Health in Mind
- In West Lothian, the Wellbeing Hub
- In Midlothian, the Midlothian Access Point
- In East Lothian, CWIC or the Mental Health and Wellbeing Hub
There is more detail on the mental health locality page.
- Antidepressants should not be used initially in mild depression (poor risk benefit ratio). In moderate depression they should be used alongside psychological therapy.
For more severe or chronic depression, or less severe depression that has not responded to lower intensity interventions above, treatment options are ideally both:
- Antidepressant treatment – which should be used alongside psychological therapies. SSRIs remain the first line drug of choice. Please see the East Lothian Formulary for more detail.
- Psychological treatment, such as Cognitive Behavioural Therapy (CBT, referral via Sci Gateway).
Patients in crisis, or at high risk of suicide, should be risk assessed and considered for emergency mental health services.
Antidepressant treatment
It is generally expected that the GP will have tried two antidepressants and considered psychological approaches, including CBT, before seeking further advice. The Formulary recommendation is to try two different SSRIs initially. Lithium for treatment and prophylaxis of recurrent major depressive disorder [unipolar depression] should only be initiated by a specialist (BNF advice)
Psychological treatment
Information about different psychological therapies and interventions can be found on the Matrix Guide to Delivering Evidence Based Psychological Therapies and Interventions in Scotland. The search facility for a particular condition or type of patient is helpful.
Information on referral criteria for psychological therapy can be found here. Accepted referrals for psychological treatment will usually involve an initial suitability assessment appointment before being added to a treatment waiting list. Some interventions are delivered in group format, but referral for this follows the same pathway and suitability assessment.
Psychology and locality mental health services are for adults aged 18-64: please refer to CAMHS or Older People’s Mental Health services for those outwith that age range. The exception is online and specific psychoeducational programmes such as Guided Self Help or cCBT.
LB & CM 26/6/26
Who to refer:
Locality Mental Health Services
If a person’s symptoms of depression have not responded to medication or psychological therapy, consider re-visiting other factors (e.g. personal, social or environmental) or adherence to treatment, and discuss options for alternative medication or psychological treatment. This is also an indication for referral. Nice guidelines have a helpful infographic to aid this.
NICE CKS summaries are very useful:
Initial primary care management with a range of patient information sources too
Ongoing management including 2nd line therapies and reducing relapse
An overview of antidepressant drug classes and their complications.
Who not to refer:
- Stable patients
- But note medication advice for stable patients can be requested without need for full referral. This can be done through SCI Gateway by marking clearly on the referral ‘Advice Only’. This may include individuals receiving Lithium treatment, multiple psychotropic medications or MAOI treatment who are not in outpatient follow up. Specific concerns may relate to the ongoing requirement for treatment, the potential side-effects of longer-term treatment or patients’ request for discontinuation.
- Patients whose needs would be better met by specialist services, such as the perinatal mental health team, the Lothian Eating Disorders Service, the learning disability team or substance use services.
How to refer:
Please refer via SCI Gateway to your locality mental health team. Please include an outline of patient’s current presentation and a brief summary of known past treatments is helpful.
- Please clearly state known risks including self-harm, vulnerability, or risk to any dependents/others.
- Please state clearly if the person is willing to consider group treatments, which usually have a shorter waiting list.
Scoring Tools
NICE defines less severe and more severe depression:
- More severe depression encompasses moderate and severe depression – PHQ9 scores ≥ 16
- Less severe depression encompasses subthreshold and mild depression – PHQ9 scores <16
NICE outlines that scores of 5, 10, and 15 are taken as cut-off points for mild, moderate, and severe anxiety respectively.
Major Depression MDI Questionnaire:
Please see scoring detail in Mental Health – Scoring of MDI Major Depression_Inventory.pdf
Self Help, Lifestyle and Community Engagement:
Online self-help resources:
Local online mental health information:
Prescribing:
Management and monitoring of patients using Lithium:
NHS Scotland / CMO Lithium guideline – https://www.sehd.scot.nhs.uk/cmo/CMO(2019)04.pdf
[Psychiatrists asking GPs to start people on Lithium should send clear instructions; and have fully counselled patients and undertaken any baseline investigations required]
Patients with renal impairment secondary to Lithium – Review Article
Lithium and chronic kidney disease; Mukesh Kripalani et al; BMJ 2009;339:b2452 (https://www.bmj.com/content/339/bmj.b2452)
