Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Judge depressive severity by symptom burden, duration, function, context, safety and psychotic or catatonic features, using measures as aids rather than thresholds and escalating severe impairment to specialist care without delay.
Severity is multidimensional. Count and intensity matter, but so do persistence, distress, function, previous course, physical health, social circumstances and danger. NICE groups subthreshold and mild presentations as less severe and moderate and severe presentations as more severe for treatment discussions, while recognising that boundaries are not defined by one number. Describe what the person cannot do, what now requires help and whether essential needs or dependants are affected.
Functional assessment should include eating, washing, dressing, sleep, medicines, money, cooking, driving, work or study, relationships, parenting and ability to seek help. Ask how much prompting, time or informal care is hidden behind task completion. A professional who still attends work may be profoundly impaired through errors and exhaustion; a person not employed should not be judged less impaired. Use goals important to the person as later outcome markers.
Psychotic features usually occur during severe episodes but require differential assessment. Delusions may concern guilt, disease, poverty, punishment, persecution or nihilism; hallucinations are often accusatory but can be mood incongruent. Ask whether the person believes organs have stopped, food is deservedly forbidden or family would benefit from their death. Explore cultural and spiritual context. Check delirium, substance use, neurological disease and a primary psychotic or bipolar disorder before fixing subtype.
Symptoms and impairment are clinically significant but essential function and safety remain sufficiently preserved for a lower-intensity option with active review.
Broader or more intense symptoms cause substantial functional loss, safety concern, marked biological change or need for combined and specialist care.
Delusions or voices amplify depressive themes such as guilt, disease, poverty, punishment, hopelessness or deserved death and influence behaviour.
Psychotic content does not clearly match depressive themes, widening consideration of bipolar, schizoaffective, primary psychotic, neurological or substance causes.
Stupor, mutism, posturing, negativism or marked excitement with physical risk requires urgent syndrome-specific medical and psychiatric assessment.
Two people with the same symptom count may require different care because function, psychosis, suicide risk, physical illness and support differ.
Professional attendance or personal grooming may depend on extreme effort and extensive support while judgement, nutrition or safety is deteriorating.
A belief that food is undeserved or organs are dead can produce medical danger even without a conventional suicide plan.
Language, literacy, pain, culture, cognitive impairment and response style can raise or lower questionnaire totals without equivalent change in illness.
Symptom improvement is incomplete when the person cannot resume essential self-care, relationships, caregiving or meaningful activity safely.
Calling depression mild solely because a questionnaire total lies below a threshold.
Assuming work attendance proves low impairment or no suicide risk.
Asking only about auditory hallucinations and missing nihilistic or guilt delusions.
Treating psychotic depression as uncomplicated low mood without specialist assessment.
Attributing stupor or mutism to refusal before assessing catatonia and physical illness.
Assuming severe diagnosis automatically removes capacity for every decision.
Improving symptoms while leaving food, housing, dependants and medicine support unaddressed.
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A patient has a moderate questionnaire score but has stopped eating, cannot manage insulin and believes they deserve to die. How should severity be judged?
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
Catatonia and profound psychomotor change are emergencies. Record movement, speech, posture, response, intake, continence and autonomic observations and assess medical and medicine causes. Severe depression can impair capacity selectively, but diagnosis does not prove incapacity. A patient may understand treatment while refusing from a value, or may be unable to weigh because a delusion makes a consequence unreal. Record the exact decision and causal evidence.
Treatment intensity follows needs and preference. Less severe depression often begins with the least intrusive psychological option the person prefers; antidepressants are not routinely offered first unless that is informed preference. More severe depression warrants a discussion of individual CBT, behavioural activation, antidepressants and combination treatment, with specialist care for psychosis, high risk, catatonia or complex resistance. Safety and physical support proceed before a complete diagnostic label.