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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Severity, functional impairment and psychotic features

Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Severe depression with loss of safety

Immediate suicidal intent, psychotic commands, refusal of food or fluids, profound self-neglect, catatonia or inability to care safely for a child or vulnerable adult requires urgent specialist and physical assessment.

Action: Stabilise medical consequences, reduce access to means, provide proportionate observation and obtain same-day mental-health review. Assess capacity for each decision, initiate safeguarding when needed and consider voluntary admission or the correct legal framework if essential care is refused.

Synopsis

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.

  • NICE describes less severe and more severe depression using symptom severity and functional impairment rather than a questionnaire cutoff alone.
  • Assess breadth, intensity, duration, persistence and trajectory of symptoms alongside self-care, relationships, work, caregiving, money and treatment use.
  • Ask what support or effort makes apparent functioning possible; attendance or good grooming can conceal major impairment and carer burden.
  • Validated scales can structure baseline and response measurement when interpreted with language, culture, physical illness and individual goals.
  • Assess suicide, self-harm, neglect, nutrition, hydration, medicines, dependants, housing and ability to use help at every severity.
  • Explore delusions by content, conviction, flexibility and behaviour and hallucinations by modality, commands, distress, control and suicide implications.
  • Psychotic depression generally requires specialist mental-health care and consideration of combined antidepressant and antipsychotic treatment.
  • ECT may be considered for severe depression when a rapid response is needed, other treatments have failed or the person has previously responded and prefers it.
  • Document severity as a reasoned formulation with evidence, immediate actions and review timing, not merely mild, moderate or severe.

Key red flags

Psychotic guilt, nihilism, poverty or deserved-punishment beliefs may drive refusal of food, shelter, medicine or life-saving care and require direct inquiry.

Mood-congruent voices can command suicide or reinforce worthlessness; apparent agreement that death is deserved may reflect delusional conviction rather than an ordinary value.

Marked psychomotor retardation, mutism, stupor, posturing or autonomic change may indicate catatonia and creates risks of dehydration, pressure injury, thrombosis and infection.

Severe functional collapse can be present despite a modest questionnaire score, especially with language difference, cognitive impairment, high premorbid ability or concealed support.

A high symptom score is not proof of unipolar depression and must not replace assessment for bipolarity, substances, physical disease, psychosis and risk.

Investigation priorities

01
Clinical severity assessmentFirst step

Integrate symptom intensity, duration, trajectory, distress, function, history, context and immediate danger.

Management branches

Severity formulationCombine symptoms with real-world function

A depressive syndrome has been identified and treatment intensity must be agreed.

  1. Describe symptom breadth, intensity, duration and trajectory and use a validated measure only as supporting evidence.
  2. Map self-care, instrumental function, relationships, roles, safety, hidden support and the person's desired outcomes.
  3. Classify needs as less or more severe with reasons and agree treatment, review timing and escalation triggers collaboratively.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

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.

  • NICE NG222 depression in adults recommendationsSeverity, function, psychotic depression, ECT and treatment choice.
  • NICE NG225 self-harm recommendationsRisk scales, psychosocial assessment and safety planning.
  • NICE NG10 violence and aggression recommendationsDe-escalation, restrictive intervention and physical monitoring.
  • NICE NG108 mental capacity recommendationsSupported, decision-specific capacity and least restriction.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom