Table 3 Barriers to participation and retention in study - Identification of depression by clinicians (Theme 1)

As the vast majority of assessments are conducted by self-harm clinicians at the time of first presentation to accident and emergency services, patients were often difficult to assess because they were distressed and intoxicated from alcohol, illicit drugs or substances ingested in the overdose.

“Most people who we get are very complex so trying to pick out depression when they have substance misuse problem, personality issues, so getting a very clear depressive diagnosis can be tricky.” (NHS Adult Site A)

While clinicians accepted that individuals were often presenting with symptoms of depression, they usually saw these as a response to life events and so should not be used to diagnose clinically significant depression. Depression was reserved for participants who had pervasive depression that was not related to life distress and was therefore uncommon.

“People overly use depression, very loosely, that isn’t depression at all, they might be unhappy about something, they might be distressed about a particular circumstance, but actually when they are not in that circumstance, and when there’s somebody else, it’s not a pervasive mood that lasts in all environments, all of the time” (NHS Child and Adolescent Site C)

Instead clinicians from CAMHS (Child & Adolescent Mental Health Services) often conceptualised emotional dysregulation instead of depression.

“I don’t tend to assess many young people who are depressed, I tend to assess people who are dysregulated, emotionally and low in mood” (NHS Child & Adolescent Site C)

Clinicians in adult services diagnosed underlying trauma or personality disorder instead of depression.

“They may hit the threshold for depression but they might not be getting a kind of diagnosis of clinical depression because it might be more sort of secondary to kind of trauma or abuse or it might be kind of diagnostically-wise personality disorder” (NHS Adult Site E)

For some clinicians, the tendency to conceptualise patients with depression who self-harmed as having personality disorder was accentuated by their reported intentions of harming themselves or others.

“I’ve lost count, it’s almost every other day at least with someone with a certain personality disorder – if you do not do this I will do this, you know I will kill my girlfriend or I will hang myself.” (NHS Adult Site B)