What questions should I ask a patient to confirm the diagnostic criteria for major depressive disorder (MDD)?

Diagnostic Questions for Major Depressive Disorder

To confirm MDD, you must systematically assess for the presence of at least 5 of 9 specific DSM-IV criteria symptoms lasting at least 2 weeks, with at least one symptom being either depressed mood or anhedonia (loss of interest/pleasure). 1

Core Screening Questions

Begin with these two essential screening questions 2:

• "Over the past 2 weeks, have you felt down, depressed, or hopeless most of the day, nearly every day?" (depressed mood)
• "Over the past 2 weeks, have you had markedly diminished interest or pleasure in activities you usually enjoy, most of the day, nearly every day?" (anhedonia)

If either answer is positive, proceed to assess all remaining criteria 1, 2.

Complete Symptom Assessment

Ask about each of the following 9 criteria, specifically inquiring whether symptoms have been present most of the day, nearly every day, for at least 2 weeks 1:

1. Depressed Mood

• "Have you been feeling sad, empty, or hopeless most of the time?"

2. Anhedonia

• "Have you lost interest or pleasure in things you normally enjoy?"

3. Appetite/Weight Changes

• "Have you experienced significant weight loss or gain (more than 5% of body weight in a month) without trying?"
• "Has your appetite increased or decreased significantly?" 1

4. Sleep Disturbance

• "Are you sleeping much more or much less than usual?"
• "Do you have trouble falling asleep, staying asleep, or are you sleeping excessively?" 1

5. Psychomotor Changes

• "Have others noticed that you're moving or speaking more slowly than usual?"
• "Have you felt restless or unable to sit still?" 1

6. Fatigue/Loss of Energy

• "Do you feel tired or lacking in energy nearly every day, even without physical exertion?" 1

7. Worthlessness/Guilt

• "Do you feel worthless or excessively guilty about things?"
• "Do you have inappropriate feelings of guilt about things that aren't your fault?" 1

8. Concentration/Indecisiveness

• "Have you had trouble thinking clearly, concentrating, or making decisions?" 1

9. Suicidal Ideation

• "Have you had recurrent thoughts of death or suicide?"
• "Have you thought about hurting yourself or made any plans to end your life?" 1

Essential Exclusion Questions

After establishing symptom criteria, you must rule out alternative diagnoses 1, 2:

• "Have you ever had periods of unusually elevated mood, increased energy, or decreased need for sleep lasting several days?" (exclude bipolar disorder) 1
• "Are you currently using alcohol, drugs, or any substances regularly?" (exclude active severe substance use disorder) 1
• "Have you started any new medications or had changes in medical conditions recently?" (exclude medical causes) 1

Functional Impairment Assessment

You must document that symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 2:

• "How have these symptoms affected your work performance?"
• "How have they impacted your relationships with family and friends?"
• "Have you withdrawn from activities or social situations?" 2

Critical Pitfalls to Avoid

• Do not assume high productivity excludes depression—highly functional individuals may maintain work performance while experiencing severe personal impairment 2
• Do not overlook depression presenting primarily as physical complaints (pain, fatigue, insomnia) without prominent mood symptoms 2
• Do not rely solely on patient self-report—high-functioning individuals may minimize emotional symptoms due to stigma 2
• Do not miss comorbid anxiety or substance use, which frequently co-occur with depression 2

Validated Screening Tools

While direct questioning is essential, consider using the Patient Health Questionnaire-9 (PHQ-9) as a structured assessment tool that directly maps to DSM-IV criteria 1, 2. The PHQ-9 takes approximately 2-5 minutes to complete and provides standardized scoring 1.

Duration and Episode Clarification

• "When did these symptoms start?" (must be at least 2 weeks) 1
• "Have you experienced similar episodes in the past?" (assess for recurrent depression) 1
• "Have these symptoms been continuous or have they come and gone?" 1

The diagnosis requires at least 5 of the 9 criteria symptoms (including depressed mood or anhedonia), present for at least 2 weeks, causing functional impairment, and not attributable to substances, medical conditions, or other psychiatric disorders. 1