Early warning signs

Depression is one of the most common chronic illnesses
throughout the world. Treating patients with depression is thought
to cost the UK upwards of £2bn each year. Yet only 15 per cent
of this figure is thought to be spent on health and social care
services directly linked to depression. The remaining 85 per cent
is linked to the indirect costs associated with social problems
such as unemployment.1

The figures are startling. Large community surveys have found that
up to a quarter of the population show depressive symptoms and that
nearly one in 10 people have a depressive illness; about one in
five women suffer from depression during their lifetime, compared
with about one in 10 men.

The average age at the onset of depression is about 40, with half
of all first episodes occurring between 20 and 50. People are most
vulnerable to the onset of major depression in their mid-20s but
cases have been reported even in childhood. Current research has
shown that the age of onset is becoming younger.2 This
may be because susceptibility to, or awareness of, depression is

Given the scale of these figures, it might be surprising that
research shows that depression is both under-diagnosed and
under-treated by doctors. In fact, about half of all patients
presenting to their doctors with depression will go unrecognised.
Depression is more likely to be recognised in people who are white,
female or middle-aged, and less likely to be recognised in young
people or those who are also physically ill.

The reasons for this are not clear but continuing education for
health and social care professionals has been almost universally
advocated. The position of the Royal College of Psychiatrists and
of general practitioners is that depression should be managed in
primary care settings.3 In fact, only about one in 10
patients are expected to leave community-based primary care to see
practitioners in secondary services, such as psychiatrists.

If it is the community where depression is to be recognised and
treated, where up to one in five people may have depressive
symptoms, an awareness of these symptoms seems essential.

So how do you recognise depression? There are many intricate
theories that attempt to explain why and how depression comes to
be, but it is perhaps more important for front-line professionals
to understand how it presents itself. It is useful to think of
depression as consisting of four changes:

  • Emotional changes which would include: no longer deriving
    pleasure from life (this is anhedonia), low mood or sadness,
    feeling hopeless or helpless, and crying spells.
  • Cognitive changes such as feelings of self-blame, self-dislike,
    guilt or the idea that other people look at you critically or talk
    disparagingly about you (these are ideas of reference). The more
    serious cognitive changes include considering suicide or self-harm
    – two-thirds of all people who commit suicide are suffering from
    depressive illness. Sometimes people have nihilistic thoughts where
    they say they have no feelings, are already dead or even that their
    insides are rotting.
  • Changes in motivation are basically slowness such as low
    energy, apathy, inability to concentrate and fatigue.
  • “Neurovegetative” or physical changes. In depressed people
    typically one might expect changes in appetite, weight, libido and
    sleep. Be especially suspicious of someone who reports waking up
    very early in the morning, and when someone’s low mood lifts
    towards the end of the day. It is often the case that the physical
    changes, or depressive symptoms, are more readily admitted to by
    patients, and the more emotional and psychological symptoms are
    only discovered with more direct questioning.

So what can community-based health and social care professionals
do with this information? First, it should be remembered that there
is no clear dividing line between normality and depression. With
this in mind it is best to use criteria that have been agreed by
specialists. If we consider simple and widely used criteria, used
by doctors, nurses, researchers, social workers and so on, we can
recognise depression in three straightforward steps of A, B and C.
A flow chart (below) can show the steps of recognition of
depressive symptoms:

If the answer to A, B and C is yes then this person may well be
depressed and getting them to talk to their doctor would be well
advised. The suggestion that they see a doctor about feeling low
may meet with some initial reservation – the stigma surrounding
mental illness is not to be underestimated. The largest hurdle can
often be having to accept that they are depressed, and therefore
mentally ill. Although many people have a significant number of
depressive symptoms they may not perceive themselves to be
“mentally ill” and might only seek help for physical symptoms such
as pain – a common complaint reported by about one in three
depressed people. The individual should be reassured that it is a
common problem, they would not be wasting their doctor’s time and
that depression is an illness just like asthma, diabetes or

Depression is common and most cases are readily treatable –
advances are continually being made in medication, therapy and
counselling. Due to the enormous number of people affected and the
under-detection by doctors, social care professionals have a
valuable part to play in identifying those affected, and ensuring
they receive timely and appropriate help. 

A. Has the person felt down or unable to experience

B. Has the person had three or more of these symptoms?

1 Poor or increased appetite/weight loss or gain

2 Sleeping less or more

3 Slowing down or speeding up (even becoming agitated)

4 Loss of energy or fatigue

5 Feelings of worthlessness, guilt or self-loathing

6 Poor concentration/indecisiveness/slowed thinking

7 Thoughts of death/suicide/self-harm

C. Has this been the case for two weeks or longer ?

Dr Samuel P Dearman, combined medical services, The Pennine
Acute Hospitals NHS Trust


1 M Knapp and S Ilson, “Economic Aspects of Depression
and its treatment”, Current Opinion in Psychiatry, 2002;
15(1): 69-75.

2 M M Weissman, R C Bland and G J Canino,
“Cross-national epidemiology of major depression and bipolar
disorder”, Journal of the American Medical Association,
1996; 276: 293-299.

3 E S Pakel and R G Priest, “Recognition And Management
Of Depression In General Practice: Consensus Statement”,
British Medical Journal, 1992; 305:1198-1202

Further reading:

Dr GS Malhi and Dr PK Bridges, Management of Depression,
Martin Dunitz 1998

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