Assessment
These are the approved guidelines published by the South African Society of Psychiatrists to provide an overview on treatment and management of commonly diagnosed psychiatric illnesses. The guidelines include consensus recommendations, based on peer contribution and using the international evidence based guidelines that are suitable for the local South African health service.
Please note that parts of this guideline may be out of date, an update will be published as soon as it is available.
A thorough diagnostic evaluation to determine both the presence of MDD and comorbid psychiatric or general medical conditions is key. This should include a review of the history of the illness including symptoms of current illness, past psychiatric and treatment history (with attention to current treatment and response to past treatment); general medical history; history of psychoactive substance abuse; personal developmental history and response to life transitions and major life events; social, occupational, and family history; mental status examination; physical examination; and laboratory investigations, as indicated.
Careful assessment of the patient’s suicidal as well as homicidal risk is paramount. The APA guidelines[1] propose evaluation of the following:
- Presence of suicidal or homicidal ideation, intent, or plans
- Access to means for suicide and the lethality of those means
- Presence of psychotic symptoms, command hallucinations in particular, or severe anxiety
- Presence of alcohol or substance use disorder(s)
- History and seriousness of previous attempts
- Family history of, or recent exposure to, suicide.
Measurement-based diagnostic tools can aid in the assessment of depression severity, presence of co-occurring disorders, and suicide risk, but should always be accompanied by a clinical diagnostic assessment incorporating a differential diagnosis.[48] Conditions that need to be excluded before making a definitive diagnosis of MDD include bipolar disorder, an adjustment disorder with depressed mood, mood disorder due to a general medical condition and a substance-induced mood disorder.
The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I)[49] and the Mini-International Neuropsychiatric Interview (MINI)[50] are clinician-rated diagnostic instruments, while the 9-item Patient Health Questionnaire (PHQ-9)[51] and the PRIME-MD are commonly used patient-rated tools.
For monitoring of depressive symptoms on treatment, the Hamilton Depression Rating Scale (HAM-D)[53] and the Montgomery-Åsberg Depression Rating Scale (MADRS)[54] are gold-standard clinician-rated scales. Other measures include the Quick Inventory of Depressive Symptomatology (QIDS)[55] which is available in both clinician-rated and patient-rated formats and the patient-rated Beck Depression Inventory (BDI).[56]
Diagnostic assessment and evaluation of patient safety, as well as that of others, should be followed by an evaluation of functional impairment and determination of the treatment setting (inpatient or outpatient).