What criteria should I use to determine if a patient with depression requires referral to secondary mental health services?

Referral to secondary mental health services for a patient with depression should be considered based on several criteria, including the severity and chronicity of symptoms, treatment response, risk factors, and specific clinical presentations.

For Adults:

• Referral for co-ordinated multidisciplinary care or specialist advice is indicated if there is more severe depression affecting personal and social functioning, which has not responded to treatment in primary care, especially with coexisting psychosocial and/or physical health risk factors ¹.
• Similarly, patients with chronic depressive symptoms affecting personal and social functioning, who have not responded to primary care treatment and have coexisting psychosocial and/or physical health risk factors, should be referred ¹.
• If there is a history or clinical suspicion of bipolar disorder, referral is appropriate ¹,⁵.
• Referral is also considered when there is a need to add an additional antidepressant medication from a different drug class due to limited or no response in primary care, or when considering switching to or from a monoamine oxidase inhibitor (MAOI) ¹.
• Consideration of other specialist combination drug treatments (e.g., combining an antidepressant with a second-generation antipsychotic, or augmentation with lithium, lamotrigine, or triiodothyronine) or physical therapy (such as electroconvulsive therapy [ECT]) warrants referral ¹.
• Urgent referral to specialist mental health services is required if a person with depression presents a considerable immediate risk to themselves or others ¹,⁵. This includes situations with an immediate risk of self-harm or suicide, warranting referral to a crisis resolution and home treatment team ³.
• Other indications for referral to a community mental health team and/or psychology services include a mental health disorder of a nature or severity requiring specialist management, cognitive impairment, high levels of distress, increasing risk of self-harm, unresponsiveness to other strategies, the person requesting specialist intervention, or high levels of distress in family members, carers, or significant others ³.
• If a practitioner is not competent to perform a mental health assessment after initial identification questions, referral to an appropriate professional is necessary ⁵.
• In cases where hospital admission for specialist mental health input is necessary but the person declines, compulsory admission under the Mental Health Act (sections 2, 3, or 4) may be arranged ¹.

For Children and Young People:

• Early referral to Child and Adolescent Mental Health Services (CAMHS) should be considered if there is evidence of depression and/or self-harm, particularly if the child or young person has been exposed to a recent undesirable life event and is identified as being at high risk (with two or more other risk factors for depression) ².
• Similarly, early referral is considered if there is evidence of depression and/or self-harm following a recent undesirable life event, and one or more family members have multiple risk histories for depression ².
• If children and young people who have previously recovered from moderate or severe depression begin to show signs of a recurrence of depression, they should be referred to CAMHS tier 2 or 3 for rapid assessment ².
• For those aged under 18 years with a thought to be a mental health disorder of a nature or severity requiring specialist management, or cognitive impairment, or experiencing high levels of distress, or increasing risk of self-harm, or unresponsiveness to other strategies, or requesting intervention from specialist services, or high levels of distress in family members, carers, or significant others, referral to CAMHS is indicated ³.