How do you assess and treat mood, thought content, and process in a patient?

Assessment and Treatment of Mood, Thought Content, and Process

Direct Assessment Approach

The initial psychiatric evaluation must include systematic assessment of mood, level of anxiety, thought content and process, and perception and cognition as core components of the mental status examination. 1

Structured Assessment Components

Mood Assessment

• Directly observe and document the patient's current mood state and level of anxiety during the clinical encounter 1
• Assess for hopelessness, which carries significant clinical implications for risk stratification 1
• Use validated screening tools when mood disturbances are suspected:
  • PHQ-9 (Patient Health Questionnaire-9) with a cutoff score of ≥8 for detecting depression in medical populations 1
  • Administer the 2-item PHQ-9 first (assessing low mood and anhedonia over the past 2 weeks); if either item scores ≥2, complete the full 9-item questionnaire 1
  • NPI-Q (Neuropsychiatric Inventory-Questionnaire) for behavioral and mood changes, particularly in cognitive disorders 1

Thought Content Assessment

• Systematically evaluate for suicidal ideation, including both active and passive thoughts of suicide or death 1

• When suicidal ideas are present, assess:

  • Patient's intended course of action if symptoms worsen 1
  • Access to suicide methods, specifically firearms 1
  • Possible motivations (attention-seeking, revenge, shame, humiliation, delusional guilt, command hallucinations) 1
  • Reasons for living (responsibility to children/others, religious beliefs) 1
  • Quality and strength of the therapeutic alliance 1

• Screen for aggressive or psychotic ideas, including thoughts of physical/sexual aggression or homicide 1

• When aggressive ideas are present, document specific content and assess risk factors 1

Thought Process Assessment

• Evaluate the logical flow and organization of thoughts through observation during the clinical interview 2

• Assess for formal thought disorders including:

  • Disorganization (primary component of thought disorder) 3
  • Verbosity 3
  • Poverty of speech 3
  • Idiosyncratic thinking 3
  • Blocking 3

• Examine speech characteristics including fluency and articulation, as these reflect underlying thought processes 1

Additional Mental Status Components

Complete the mental status examination by assessing:

• General appearance and nutritional status 1
• Coordination and gait 1
• Involuntary movements or abnormalities of motor tone 1
• Sight and hearing 1
• Skin examination for stigmata of trauma, self-injury, or drug use 1

Obtaining Collateral Information

Incorporate informant-based assessment using structured instruments when evaluating mood and behavioral changes 1

• Obtain reliable information from an informant regarding changes in cognition, activities of daily living, mood, and neuropsychiatric symptoms 1
• Use validated tools such as:
  • AD8 (Ascertain Dementia 8) for cognitive and functional changes 1
  • IQCODE (Informant Questionnaire on Cognitive Decline in the Elderly) for rating change from baseline 1
  • NPI-Q for behavioral symptoms 1

Risk Documentation

Document an estimate of suicide risk including all factors influencing risk in every initial psychiatric evaluation 1

• When aggressive ideas are present, document estimated risk of aggressive behavior (including homicide) with contributing factors 1

Treatment Approach

Collaborative Decision-Making

Engage the patient in shared decision-making by:

• Asking about treatment-related preferences 1
• Explaining the differential diagnosis, risks of untreated illness, treatment options, and benefits/risks of treatment 1
• Collaborating on decisions pertinent to treatment 1

Treatment Selection Based on Findings

For psychotic thought content:

• Consider antipsychotic medications when psychotic symptoms are present 4, 5
• Olanzapine (5-20 mg/day) has demonstrated efficacy for psychotic symptoms in schizophrenia and bipolar disorder 4
• Risperidone (1-6 mg/day) is effective for acute manic episodes with psychotic features 5

For mood disturbances:

• Address underlying mood disorders when thought content is influenced by depressive or manic symptoms 1
• Recognize that thought content and mood are bidirectionally related, with negative thought content predicting subsequent negative mood 6

Documentation Requirements

Document the following in every evaluation:

• Rationale for treatment selection, including specific factors influencing treatment choice 1
• Estimated suicide risk with contributing factors 1
• Rationale for any clinical tests ordered 1

Critical Pitfalls to Avoid

• Do not rely solely on symptom counts when assessing depression; use phased screening that incorporates risk factors and functional impairment 1
• Never omit assessment of suicidal ideation out of concern for "planting ideas"—this is a required component of the mental status examination 1
• Do not attribute thought disorders solely to mania or attentional disturbances—these are independent dimensions requiring separate assessment 3
• Avoid interpreting cognitive screening results without considering education level, language barriers, and cultural factors 2
• Do not conduct evaluations without obtaining collateral information when cognitive impairment or behavioral changes are suspected 1