• Depression is suggested by feelings of persistent sadness or low mood, loss of interest or pleasure, and low energy.
• Associated symptoms of depression that may also be present include:
• Disturbed sleep.
• Poor concentration or indecisiveness.
• Low self-confidence.
• Poor or increased appetite.
• Agitation or slowing of movements.
• Guilt or self-blame.
• Suicidal thoughts or acts.
• Diagnosis of a depressive episode is identical to that for unipolar depression. For more information, see the section on Assessment and diagnosis in the CKS topic on Depression, and the section on Diagnosis in the CKS topic on Depression in children.
• The presence of coexistent hypomanic or manic symptoms may suggest the person is having a mixed episode.

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• Risk assessment determines the urgency of referral to specialist mental health services.
• Assess the risk of suicide:
• Consider risk factors for suicide, such as:
• Previous suicide attempt.
• Hopelessness.
• Assess for suicidal ideation:
• Ask a single question such as 'Are you feeling suicidal?'
• If the answer is yes, assess for suicidal intent.
• Assess for suicidal intent by asking:
• Have you made any plans for ending your life?
• Do you have the means for doing this available to you?
• What has kept you from acting on these thoughts?
• Consider other risks of harm to the individual:
• Self-neglect.
• Exploitation by others.
• Alcohol and substance misuse.
• Consider the risks of harm to others, including:
• To family, in particular children and other dependents, from:
• Neglect.
• Depressive or paranoid delusions.
• To the public from:
• Rarely, violence and aggression arising from psychotic symptoms.

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• Determine the urgency of any referral by assessing the risks to the individual and others.
• Admit urgently those people who are considered to be a danger to themselves or others.
• If admission is thought to be necessary but the person refuses, see Compulsory admission.
• Refer urgently for specialist mental health assessment:
• People for whom the degree of risk is increasing such that they are likely to become a danger to themselves or others.
• People with severe depression.
• People in a mixed episode.
• People with rapid cycling.
• For people on anti-manic medication, check that they are taking their medication at the prescribed dose and encourage adherence.
• For people with moderate depression and no increase in the degree of risk to self or others:
• Arrange a prompt specialist mental health review.
• Contact a mental health specialist for advice on initial management whilst the person is waiting to be seen.
• For people with mild depression:
• Provided the person's previous episodes of mild depression have not developed into chronic or more severe depression (and a more severe depression is not likely), an initial period of watchful waiting may be appropriate.
• Arrange for repeat further assessment in primary care or by their mental health professional within 2 weeks (1 week in children and adolescents).
• If the person's previous episodes of mild depression have developed into chronic or more severe depression, or a more severe depression is otherwise likely:
• Seek specialist mental health advice and consider an early specialist mental health review.
• All pregnant women presenting with depression should be referred. For more information, see Depressive episode in pregnancy.
• Whilst awaiting specialist assessment, alter or start treatment only on specialist advice.
• Children and adolescents should only be treated by specialists.

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• Take regular exercise, preferably as part of a structured exercise programme.
• Try to schedule regular activities and have a daily routine.
• Engage in both pleasurable and goal-directed activities.
• Ensure adequate diet and sleep.
• Seek appropriate social support.

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• Driving must cease during the acute illness.
• For further information on the DVLA's medical rules regarding hypomania/mania, severe depression, or acute psychotic disorders see the DVLA 'At a glance guide' at www.dvla.gov.uk/medical/ataglance.
• Advise the person that it is their responsibility to inform the Driver and Vehicle Licensing Agency (DVLA) of any condition that may affect their ability to drive. The General Medical Council guidelines advise breaking patient confidentiality and informing the DVLA if the person cannot understand that driving during psychosis is unsafe (usually because of lack of insight into their illness) or if the person refuses to stop driving.

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• If the person needs to be admitted to hospital, every attempt should be made to persuade them to go voluntarily.
• If the person refuses to go to hospital, compulsory admission may be necessary if the person:
• Requires assessment and/or treatment in a hospital, and
• Needs to be admitted in the interests of their own health or safety, and/or for the protection of other people.
• Compulsory admission is arranged using the appropriate section (usually section 2) of the Mental Health Act (MHA):
• Section 2 allows for compulsory admission for up to 28 days.
• It requires an application from an Approved Mental Health Professional (AMHP, formerly an Approved Social Worker), or, rarely, the person's nearest relative, and recommendations from two doctors, one of whom is section 12-approved (usually a psychiatrist) and one who has previous acquaintance with the individual (usually the person's GP if at all practicable).
• Ideally the person should be examined jointly by the two doctors with the AMHP also present. Where this is not possible, each doctor may carry out a separate examination. If the AMHP is not present it is essential that at least one of the doctors discusses the person with the AMHP.
• Section 4 is used in exceptional cases to permit compulsory admission for up to 72 hours if there is 'urgent necessity', and 'undesirable delay' would occur while trying to arrange admission under section 2.
• It requires an application from an AMHP (or, rarely, the person's nearest relative) and just one medical recommendation, preferably from a doctor with previous acquaintance (usually the GP).
• Section 136 may be used by police to take someone from a public place to a place of safety and enable the person to be examined by a registered medical practitioner and interviewed by an Approved Social Worker. The person's GP, where known, may be informed.

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