How do you manage a depressive episode in primary care?
Depression is common in primary care but is not the same as distress or ordinary low mood. A structured approach helps GPs distinguish true depressive episodes from adjustment reactions, confirm severity, assess risk, and match treatment to the person's needs and preferences. The current NICE guideline (NG222) frames new episodes as less severe or more severe depression rather than the older mild, moderate, and severe categories, which changes first-line treatment choices.
Step-by-Step Guide
1. Screen with the two identification questions
Be alert to possible depression, especially in people with a past history of depression or a chronic physical health problem with functional impairment. Ask:
- During the last month, have you often been bothered by feeling down, depressed, or hopeless?
- During the last month, have you often been bothered by having little interest or pleasure in doing things?
A "yes" to either warrants further assessment.
2. Conduct a comprehensive assessment
If you are competent to perform a mental health assessment, review the person's mental state and associated functional, interpersonal, and social difficulties. If not, refer to an appropriate professional. The assessment should not rely on a symptom count alone. Cover:
- Symptom severity and duration
- Degree of functional impairment or disability
- Previous history of depression and treatments
- Contributing factors: personal history, past trauma, social and interpersonal factors, substance use, and any chronic physical illness
- Direct questioning about suicidal ideation and intent
3. Use a validated measure to grade severity
Consider using a validated tool such as the PHQ-9 to inform and evaluate treatment. The guideline uses a PHQ-9 score of 16 as a threshold: scores below 16 indicate less severe depression, and scores of 16 or more indicate more severe depression. Severity reflects symptoms, duration, and impact on functioning together.
4. Assess risk of self-harm and suicide
Always ask directly about suicidal ideation and intent. If there is risk:
- Assess social support and awareness of help sources
- Arrange help appropriate to the level of need
- Advise the person to seek further help if things deteriorate
If the person presents considerable immediate risk to themselves or others, refer urgently to specialist mental health services. When prescribing for someone at significant risk of suicide, account for toxicity in overdose; do not routinely start with tricyclics except lofepramine.
5. Discuss treatment options and preferences
Discuss what the person thinks may be contributing, their previous treatment experiences, and what they hope to gain. Offer information on NICE-recommended treatments, expected benefits and harms, waiting times, and delivery options. Match the least intrusive, most resource-efficient treatment that fits their clinical needs, or one that worked before.
6. Treat less severe depression
For less severe depression, first-line options include guided self-help, group behavioural activation, group exercise, individual behavioural activation, individual cognitive behavioural therapy, or interpersonal psychotherapy. Do not routinely offer antidepressants as first-line treatment, because there is no evidence of benefit compared with placebo. Consider an antidepressant, usually an SSRI, when there is a history of more severe depression, persistent subthreshold symptoms for at least two years, no response to psychological therapy, or mild depression complicating a long-term physical condition.
7. Treat more severe depression
For more severe depression, offer both psychological therapy and antidepressant medication. Options include individual CBT, individual behavioural activation, interpersonal psychotherapy, or guided self-help, combined with an SSRI. A patient may need to be established on medication before they can engage with psychological therapy. Avoid tricyclics as first-line because of overdose risk.
8. Arrange follow-up and monitoring
Review treatment between 2 and 4 weeks after starting. Monitor concordance, side effects, and suicidal ideation, particularly in the early weeks. For people aged 18 to 25 or at increased suicide risk, review 1 week after starting or increasing an antidepressant. Antidepressants usually take effect within 4 weeks. Treatment should continue for at least 6 months after remission. If there is no or limited response, reconsider the diagnosis, increase intensity, switch treatments, or add combination therapy.
Red Flags Requiring Urgent Action
Refer urgently to specialist mental health services or direct to crisis services if you identify:
- Active suicidal intent or a specific plan
- Considerable immediate risk to self or others
- Severe self-neglect, including poor oral intake
- Psychotic symptoms such as delusions or hallucinations
- Symptoms of bipolar disorder, including elevated mood or grandiosity that suggests a previous misdiagnosis
- Marked and prolonged agitation after starting treatment
Common Questions
When should I use the PHQ-9? Use it during assessment to grade severity and inform treatment choice, and repeat it during follow-up for routine outcome monitoring. A score of 16 or more indicates more severe depression and supports offering combined therapy with an antidepressant.
How long should someone stay on an antidepressant? Treatment should continue for at least 6 months after symptoms remit, with regular review. Stopping should be a shared decision, tapered in steps, and monitored for withdrawal symptoms and relapse. Withdrawal can last weeks or months and is not the same as relapse.
What if the person also has anxiety? When depression is accompanied by anxiety, the first priority is usually to treat the depression. If the person has a primary anxiety disorder with comorbid depressive symptoms, consult the relevant anxiety disorder guidance and consider treating the anxiety first.
Should I manage young adults differently? Yes. For people aged 18 to 25 or those at increased suicide risk, assess mental state before prescribing, put a risk management strategy in place, and review 1 week after starting or increasing the dose, then no later than 4 weeks.
Protocol Summary
- Screen with the two depression identification questions
- Conduct a comprehensive assessment if either is positive
- Grade severity with a validated measure such as the PHQ-9
- Ask directly about suicidal ideation and assess risk
- Discuss treatment options and reach a shared decision
- Offer psychological therapy or guided self-help first for less severe depression
- Offer combined psychological therapy and an SSRI for more severe depression
- Review within 2 to 4 weeks, or 1 week for those at increased suicide risk
- Refer urgently for active suicidal intent, severe self-neglect, or psychotic symptoms
How Rovetia Helps
Depression management spans assessment, risk stratification, treatment trials, and repeated follow-up over months. Rovetia brings the full patient timeline together from consultation notes, questionnaire results, and voice memos into one searchable record. When a patient returns, you can quickly review their PHQ-9 trajectory, what was offered, response to treatment, and the agreed safety plan, without piecing together scattered notes. AI-assisted structured data extraction keeps the clinical picture organized across visits so risk and response stay visible throughout the episode.
Sources
- Recommendations | Depression in adults: treatment and management | Guidance | NICE
- Quality statement 1: Assessment | Depression in adults | Quality standards | NICE
- Depression in adults