Depression History Taking

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Taking a depression history is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking a depression history in an OSCE setting.


Tips

Some general tips when taking a history of depression:

  • Use the patient’s own language when describing their feelings and use this to get them to expand on their presenting symptoms. Repeating parts of phrases can help develop the consultation and show the patient you are listening and trying to understand.
  • Be careful with your “active listening” fillers – nodding and making affirmative noises to show engagement may be more appropriate than saying “Okay…”, however, be careful not to accidentally re-affirm some of the patient’s negative beliefs about themselves or their situation.
  • Don’t be afraid to (sensitively) ask about suicide risk. Screening for risk and asking about suicide does not increase the likelihood of a patient attempting it!

Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Ask the patient if they’d be happy to talk with you about their current issues.


Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

  • “How are you today?”
  • “How have you been feeling recently?”
  • “What’s brought you in to see me today?”
  • “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand on their presenting complaint if required:

  • “Ok, can you tell me more about that?”

Open questions can help the patient to explain how they are feeling, without placing words into their mouth or assuming a specific reason for presentation.


Screening for depression

Depression should be screened for in at-risk individuals (e.g. those with a past history of depression or a chronic health problem with secondary functional impairment).

NICE guidelines recommend the questions below to briefly screen for depression.

“During the past month have you…”

  • “Felt low, depressed or hopeless?”
  • “Had little interest or pleasure in doing things?”

If there is an affirmative answer to either of these questions, further evaluation should be performed. It should be noted that a negative response to the questions does not exclude depression.


Exploring symptoms of depression

Biological symptoms

Sleep cycle disruption

Questions useful for exploring sleep disruption include:

  • “How has your sleeping pattern been recently?”
  • “Have you had any difficulties with getting to sleep?”
  • “Do you find you wake up early, and find it difficult to get back to sleep?”

Low mood

Patients with depression typically experience persistent sadness/low mood on most days.

Explore the patient’s recent mood:

  • “How has your mood been recently?”
  • “How often have you felt sad recently?”
  • “Are there any particular times of day that you notice your mood is worse?”
  • “Does your mood vary throughout the day?”

Appetite changes

The appetite of patients with depression can be significantly altered:

  • “Have you noticed a change in your appetite?”
  • “What is your diet like at the moment?”
  • “What are you eating on a typical day?”

Reduced libido

Patients with depression often experience reduced libido:

  • “Have you noticed a change in your libido recently?”
  • “Since you have been feeling this way, have you noticed a difference in your sex drive?”

Cognitive symptoms

Screen for, and assess the extent of any cognitive symptoms of depression.

Reduced concentration

Patients with depression typically exhibit reduced levels of concentration:

  • “How are your current levels of concentration?”
  • “Can you follow TV programmes/ read the newspaper/*insert hobby here* without getting distracted?”

Negative perception of current/future situation

Patients with depression typically demonstrate a negative perception of their current and future situation:

  • “How do you feel about your current situation?”
  • “How do you feel about the future?”

Negative perception of self

Patients with depression often exhibit a negative perception of themselves:

  • “How do you feel about yourself?”
  • “Do you often criticise yourself?”
  • “Do you blame yourself when things go wrong?”

Assess suicide risk

Patients with depression are at an increased risk of suicide and self-harm, therefore assessment of an individuals risk is essential to inform appropriate management.

Questions that can be useful to determine a patient’s risk of suicide include:

  • “When people feel down and depressed, they can feel that life is no longer worth living. Have you ever felt like this?”
  • “Have you had any thoughts of taking your life?” 
  • “How often do you think about taking your life?”
  • “Have you thought about how you would end your life?”
  • “Have you made any plans to end your life?”
  • “Have you ever tried to take your own life?”
  • “Have ever thought about hurting yourself?
  • “Have you tried to hurt yourself in any way?”
  • “What things do you have that you feel stop you from ending your life?”
  • “Are you drinking alcohol or using recreational drugs at the moment?”
  • “Have you felt able to see your friends and socialise recently?”

See our suicide risk assessment guide for more details.


Screening for other psychiatric diagnoses

It’s important to consider other psychiatric diagnoses which may also present with depression including:

  • Bipolar disorder
  • Schizophrenia

Screen for features of mania suggestive of bipolar disorder:

  • “Have you ever experienced periods of feeling particularly high, energetic or euphoric?”

Screen for features of schizophrenia:

  • “Have you ever heard voices speaking when there seems to be no-one around?”
  • “Do you ever feel that people are discussing you negatively?”
  • “Do you fear that people may be out to get you?”
  • “Have you ever felt that something or someone is able to put thoughts into your head?”
  • “Have you ever felt that something or someone can remove thoughts from your brain?”
  • “Have you ever felt that something or someone can hear your thoughts?”
  • “Have you noticed any sensations that seem odd or inexplicable?”

Past psychiatric history

Previous episodes of depression:

  • “Have you ever had any other periods of feeling particularly low?”
  • “Have you ever been told you have depression in the past?”
  • “Have you ever received any treatment(s) for depression in the past and if so, did they help?”

General psychiatric history:

  • “Have you previously had any problems with your mental health?”
  • “Have you ever been diagnosed with a psychiatric condition?”
  • “What treatment(s) did you receive for this diagnosis and did they seem to help?”
  • “Have you ever been admitted to the hospital because of your mental health?” 

Past medical history

Ask if the patient has any medical conditions: 

  • “Do you have any medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”

Note any medical conditions which may directly cause mood disturbance through physiological mechanisms (e.g. hypothyroidism).

Chronic illness is also a major risk factor for depression (e.g. chronic pain, cancer, etc).

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).


Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications, document the medication namedosefrequencyform and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”

Family history

Ask the patient if there is any family history of psychiatric disease in first-degree relatives:

  • “Have any of your parents or siblings had problems with their mental health in the past?”
  • “Do you know what type of mental health problems they had?”

It may be useful to draw a genogram displaying this information.


Social history

Explore the patient’s social history to both understand their social context and identify potential psychiatric risk factors.

General social context

Explore the patient’s general social context including:

  • the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
  • who else the patient lives with and their personal support network
  • what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)

Assess the impact of patient’s depressive symptoms on their relationships and work:

  • “Has your mood affected your friendships?”
  • “Are you able to socialise regularly with others?”
  • “Are you in a relationship at the moment? Has this been affected?”
  • “Have you told any friends/family/anyone how you are feeling?”
  • “Has your mood affected your ability to work?”
  • “Are you able to concentrate on tasks at work?”
  • “Has your mood caused you to take any time off work?”

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Alcohol

Record the frequencytype and volume of alcohol consumed on a weekly basis.

See our alcohol history taking guide for more information.

Recreational drug use

Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use. Recreational drugs may be the underlying cause of a patient’s presentation with psychiatric symptoms.

Gambling

Ask the patient if they gamble and if they feel this is a problem.

Gambling is causative of several decrements to health directly, such as increased sedentary behaviour during the time spent gambling, poor sleep, reduced levels of self-care and anxiety. Patients with a gambling problem are also more likely to have substance misuse issues.1

Problematic gambling can be assessed via the Problem Gambling Severity Index (PGSI).


Insight

Insight refers to the ability of a patient to understand that they have a mental health problem and that what they’re experiencing is abnormal. Patients with severe depression may demonstrate loss of insight into their illness.

Some examples of questions which can be used to assess insight include:

  • “What do you think the cause of the problem is?”
  • “Do you think you have a problem at the moment?”
  • “Do you feel you need help with your problem?”

Closing the consultation

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


References

  1. World Health Organisation. The epidemiology and impact of gambling disorder and other gambling-related harm. Published 26-28 June 2017. Available from: [LINK].

 

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