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Depression from period3/2/2024 Third, it does not take into account illness duration and course. Second, it implies that the different symptoms experienced are equivalent, although, in fact, symptom patterns may be important. First, this classification appears to have often been implemented with an emphasis on a symptom count alone with other important factors such as duration and social impairment ignored, although it should be noted that in general there is a relationship between the number of symptoms and severity of functional impairment ( Faravelli et al., 1996). ![]() ![]() The subsequent categorisation of depression into mild, moderate and severe has led to a number of concerns in practice. The approach adopted in the first NICE depression guideline ( NICE, 2004a NCCMH, 2004) was based on ICD–10 and rested on a dimensional approach based on a symptom count further elaborated by taking into account the presence of social role impairment and the duration of both symptoms and social impairment. This conflicts with the recognised need to take multiple factors/dimensions into consideration within a consultation, including the patient's view on the cause of symptoms and acceptable treatment, and in this guideline and the depression guideline update a major challenge has been to provide a useful categorisation that adequately captures the complexity.ĬLASSIFICATION OF DEPRESSION AND NICE GUIDANCE Clinicians are often required to make a categorical decisions – for example to treat with antidepressants or not, to refer for further interventions or not- and consequently there can be pressure to interpret data on a single dimension in a categorical way, for example, treat or not treat based solely on a symptom severity rating (for example, a PHQ-9 score alone). Categories help distinguish cases from non-cases, whilst dimensions help identify severe disorder from mild ( Cole et al., 2008). A major concern is whether depression should be classified using dimensions or categories. The lack of a highly reliable or valid classificatory system has significant and practical clinical consequences, particularly in primary care where the full range of depression presents. Lower severity and duration of a depressive episode predicts, to some extent, a greater likelihood of spontaneous or earlier and eventual improvement whereas greater severity, chronicity and number of previous episodes predict a higher chance of subsequent relapse. The classification has some use in describing likely outcome and course ( Khan et al., 1991 Barrett et al., 2001 Sullivan et al., 2003 Blom et al., 2007 Jackson et al., 2007 Conradi et al., 2008 Holma et al., 2008 Van et al., 2008) although social support, social impairment or personality factors also need to be taken into account. Other aspects of depression such as response to treatment (for example, treatment resistant, refractory) and aetiology (for example, preceding life events) do not feature specifically in the classifications and lack accepted definitions, although are used in clinical practice. ![]() These have defined a threshold of severity of clinical significance with further classification in terms of severity (for example, mild, moderate or severe as adopted in DSM–IV with regard to major depressive disorder), duration and course of the disorder (for example, recurrent, presence of residual symptoms) and subtype based on symptom profile (for example, melancholic, atypical). Over time pragmatic definitions have emerged, enshrined in the current two major classification systems, DSM–IV ( APA, 2000a) and ICD–10 ( WHO, 1992). These have been based on varying combinations of the nature, number, severity, pattern and duration of symptoms, and in some cases the assumed aetiology. A number of classification systems/subgroupings have been used, including reactive and endogenous depression, melancholia, atypical depression, depression with a seasonal pattern/seasonal affective disorder and dysthymia. Despite considerable work on the aetiology of depression including neurobiological, genetic and psychological studies, no reliable classificatory system has emerged that links either to the underlying aetiology or has proven strongly predictive of response to treatment. This appendix sets out an approach to the classification of depression that was used in the development of this guideline and the depression guideline update ( NCCMH, 2010) (including the analysis of the evidence and the development of recommendations) and will be of value in routine clinical use.ĭepression is a heterogeneous disorder in which a number of underlying presentations may share a common phenomenology but have different aetiologies.
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