Diagnosing Major Depression

A diagnosis of major depression requires five or more of the symptoms listed below (using the mnemonic SAD A FACES) to have been present over the same two-week period, with at least one symptom being either depressed mood or loss of interest or pleasure. The symptoms must not be due to a general medical condition or the direct effects of a substance. They must be causing clinically significant distress or impairment in social, occupational or other important areas of functioning. SAD A FACES symptoms involve:

Common Symptoms of Unipolar Depression


Screening and Assessment

Tools for Mood Disorders

Primary care practitioners may make use of structured and semi-structured instruments aimed at screening for psychiatric disorders and making clinical diagnosis more accurate and objective. Although useful, such tools should be considered a supplement to, not a substitute for, the clinical interview.

Three categories of instruments are currently available:



General guidelines for treatment

The most common clinical error that leads to therapeutic failure of an antidepressant is prescribing too low a dose for too short a period of time. Unless side-effects prevent it, the dosage of an antidepressant should be raised to the maximum recommended level and maintained for at least four to eight weeks before a trial is considered unsuccessful. The antidepressant treatment should be maintained for at least six months once the client recovers from the illness. Recurrent episodes and episodes involving significant suicidal ideation or impairment of psychosocial functioning should lead to prophylactic treatment. When an antidepressant is stopped, the drug should be tapered slowly to minimize risk of discontinuation symptoms.

In general, second- and third-generation antidepressants (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs], norepinephrine and dopamine reuptake inhibitors [NDRIs] or noradrenergic and specific serotonergic antidepressants [NaSSAs]) are drugs of choice when initiating antidepressant therapy, as they are well tolerated and safe in overdose. TCAs may be used in clients who do not respond to the first-line antidepressants or who are unable to tolerate their side-effects. Among the TCAs, nortryptiline and desipramine are better tolerated.

Some clients fail to respond to repeated trials of medications. Strategies in those cases include a referral to a specialist where use of drug combinations, high-dose therapy, use of unconventional drugs, electroconvulsive therapy and other experimental treatments can be implemented, as shown in Figure 1. A high risk of suicide, an inability to get food and shelter and the lack of a support system may lead to hospitalization.

Steps for Managing Major Depressive Disorder

  • Perform a diagnostic evaluation.
  • Determine whether there are psychiatric and general medical comorbidities.
  • Evaluate clients' safety and that of others.
  • Determine the treatment setting: hospital or outpatient.
  • Consider hospitalization if a serious threat to self or others exists or if clients are severely ill and lack adequate social support.
  • Establish and maintain a therapeutic alliance.
  • Monitor psychiatric status and safety.
  • Provide education to the client and family, when appropriate.
  • Enhance medication adherence.
  • Address early signs of relapse.


Summary of management strategies for bipolar disorders

  • Perform a diagnostic evaluation.
  • Assess presence of alcohol or other substance use disorder.
  • Evaluate for general medical conditions.
  • Rule out common medications causing or contributing to mania.
  • Ensure safety of clients and others.
  • Carefully assess risk of suicide.
  • Determine treatment setting.
  • Consider limiting access to vehicles, credit cards, bank accounts, cell phones, etc., because of risk of reckless behaviour.
  • Establish and maintain a therapeutic alliance.
  • Educate clients and family.
  • Enhance treatment adherence.
  • Promote awareness of stressors and regular patterns of activity and sleep.
  • Work with the client and family to anticipate and address early signs of relapse.
  • Evaluate and manage functional impairments.