How to assess the degree of distress and functional impairment in a patient with mood dysfunction?

Assessment of Distress and Functional Impairment in Mood Dysfunction

Use validated screening tools with established cutoffs to quantify both symptom severity and functional impact, then conduct targeted diagnostic assessment when scores exceed clinical thresholds.

Initial Screening Approach

Primary Screening Tools

Start with the PHQ-9 for depression and GAD-7 for anxiety as your first-line screening instruments 1. These tools directly assess both symptom severity and functional impairment in a single instrument.

• PHQ-9 scoring thresholds: 1-7 (minimal), 8-14 (moderate), 15-19 (moderately severe), 20-27 (severe depressive symptomatology) 2
• GAD-7 scoring thresholds: ≥5 (mild anxiety), ≥10 (moderate anxiety), ≥15 (severe anxiety) 1, 2
• Critical safety item: Never skip item 9 on the PHQ-9 regarding self-harm thoughts—any positive response requires immediate risk assessment regardless of total score 2, 3

Alternative Screening Options

For specific populations where PHQ-9 may be less accurate:

• Elderly patients: Use the Geriatric Depression Scale (GDS-30 or GDS-SF-15), with cutoffs of ≥19 for full scale or ≥5 for short form 1
• Patients with cognitive impairment: PHQ-9 loses accuracy; use clinician-administered tools like the Hamilton Rating Scale for Depression (HAM-D) instead 3, 4
• Cancer or medically ill patients: Consider the Hospital Anxiety and Depression Scale (HADS), which excludes somatic symptoms that may be confounded by medical illness; scores ≥8 on either subscale indicate caseness 1

Distress Thermometer for Rapid Assessment

The Distress Thermometer (DT) provides a single-item global distress measure ranging from 0 (none) to 10 (extreme distress) 1.

• Recommended cutoff: DT ≥4 for mixed populations 1
• Enhanced assessment: Combine DT with Impact Thermometer (IT) to assess functional impact—DT ≥5 plus IT ≥4 suggests depression with significant functional impairment 1
• Advantage: Can be administered in under 1 minute, making it practical for busy clinical settings 1

Assessing Functional Impairment Specifically

Sheehan Disability Scale (SDS)

The SDS is the gold standard for quantifying functional impairment across three domains: work/school, social life, and family/home responsibilities 5.

• Functional remission threshold: SDS ≤7 equates to remission of depression symptoms (HAM-D ≤7) 5
• Clinically meaningful change: A 3-point difference on the SDS represents clinically significant improvement in functional status 5
• Scoring: Each domain rated 0-10, with total scores ranging from 0-30 (higher scores indicate greater impairment) 5

WHO-5 Well-Being Index

The WHO-5 assesses emotional well-being and quality of life with five items rated over the past two weeks 5.

• Clinically meaningful change: A 2.5-point difference represents significant improvement in well-being 5
• Scoring: Ranges from 0-25, with lower scores indicating poorer well-being 5

Domain-Specific Functional Assessment

For comprehensive evaluation, assess these specific functional domains 6, 7:

• Occupational functioning: Ability to work, productivity, absenteeism 6
• Cognitive functioning: Concentration, memory, decision-making capacity 7
• Interpersonal relationships: Social interactions, family relationships 6
• Autonomy: Self-care, independent living skills 6
• Leisure activities: Ability to enjoy hobbies and recreational activities 6

Diagnostic Assessment Algorithm

When to Proceed to Full Diagnostic Assessment

Conduct comprehensive diagnostic evaluation when 1, 2:

• PHQ-9 ≥8 2
• GAD-7 ≥10 2
• DT ≥4 with concerning problem list items 1
• Any positive response to suicidal ideation questions 2, 3

Diagnostic Criteria Application

For major depressive disorder diagnosis, confirm at least 5 of 9 DSM-IV symptoms present during the same 2-week period, with at least one being either depressed mood or anhedonia 3, 8.

The nine symptoms are:

• Depressed mood
• Loss of interest or pleasure (anhedonia)
• Significant weight change or appetite disturbance
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Diminished concentration or indecisiveness
• Recurrent thoughts of death or suicidal ideation 8

Critical requirement: Symptoms must cause clinically significant distress or functional impairment 3, 8.

Common Pitfalls and How to Avoid Them

Medical Causes Must Be Excluded First

Before diagnosing a primary mood disorder, rule out medical and substance-induced causes 1, 3:

• Uncontrolled pain or fatigue 1
• Delirium from infection or electrolyte imbalance 1
• Thyroid disorders 3
• Medication side effects (e.g., interferon, corticosteroids) 1
• Substance use or withdrawal 1

Bipolar Disorder Screening

Screen for bipolar disorder risk before initiating antidepressant treatment 9. Obtain detailed psychiatric history including:

• Personal history of manic or hypomanic episodes 9
• Family history of bipolar disorder, suicide, or depression 9
• Previous antidepressant-induced mood elevation or agitation 9

Severity-Specific Functional Impairment Patterns

Depressive symptoms cause greater functional impairment than manic symptoms 6. Even euthymic bipolar patients show persistent functional deficits compared to healthy controls 6.

• During depression: Expect the most severe functional impairment across all domains 6
• During hypomania/mania: Moderate functional impairment, but less than depression 6
• During remission: Residual functional deficits may persist despite mood symptom resolution 6, 7

Emergency Situations

Immediate referral for emergency psychiatric evaluation is required when 1, 2:

• Any patient identified as at risk of harm to self or others 1
• Positive response to PHQ-9 item 9 with specific plan or intent 2, 3
• DT ≥5 with IT ≥5 (depression with suicidal ideation) 1

Practical Implementation Strategy

Step 1: Universal Screening

Administer PHQ-9 and GAD-7 to all patients with suspected mood dysfunction 1, 2.

Step 2: Assess Functional Impact

Add SDS to quantify functional impairment across work, social, and family domains 5.

Step 3: Risk Stratification

• PHQ-9 1-7: Minimal symptoms, monitor 2
• PHQ-9 8-14: Moderate symptoms, consider low-intensity interventions 2
• PHQ-9 ≥15: Severe symptoms, refer to psychiatry/psychology 2
• Any suicidal ideation: Emergency evaluation 2, 3

Step 4: Diagnostic Confirmation

For scores above threshold, conduct structured diagnostic interview to confirm DSM-IV criteria and assess for medical causes 1, 3.

Step 5: Treatment Planning

Base treatment intensity on both symptom severity and functional impairment, not symptoms alone 7, 5. Full functional recovery—not just symptom remission—should be the treatment goal 7.