What is the process for assessing a person's mood?

Mood Assessment: A Systematic Approach

Mood assessment should begin with the Patient Health Questionnaire-9 (PHQ-9) as the primary screening tool, followed by structured evaluation of anxiety symptoms, risk assessment for self-harm, and identification of medical or substance-induced causes. 1, 2

Initial Screening Process

Step 1: Primary Depression Screening with PHQ-9

• The PHQ-9 should be administered first to all patients requiring mood assessment, using a cutoff score of ≥8 for detecting depression in medical populations. 2
• Begin with the 2-item PHQ-9 assessing low mood and anhedonia over the past 2 weeks; if either item scores ≥2, complete the full 9-item questionnaire. 2
• PHQ-9 scores are interpreted as follows: 1-7 (minimal symptoms), 8-14 (moderate symptoms), 15-19 (moderate to severe symptoms), and 20-27 (severe symptoms). 3
• Patients with PHQ-9 scores ≥15 require referral to psychiatry or psychology. 3

Step 2: Anxiety Assessment

• Following depression screening, assess anxiety symptoms using the Generalized Anxiety Disorder-7 (GAD-7) scale. 1
• The GAD-7 total score ranges from 0 to 21, with interpretation as follows: 0-4 (minimal anxiety), 5-9 (mild anxiety), 10-14 (moderate anxiety), and 15-21 (severe anxiety). 1
• Scores of ≥5,10, and 15 indicate mild, moderate, and severe levels of anxiety respectively. 1

Critical Safety Assessment

Immediate Risk Evaluation

• Before proceeding with further assessment, evaluate for risk of harm to self or others, severe depression or agitation, psychosis, or confusion (delirium), all of which require immediate referral to a psychiatrist, psychologist, physician, or equivalently trained professional. 1, 2
• Systematically evaluate for both active and passive suicidal ideation, including thoughts of suicide or death. 2
• When suicidal ideas are present, assess the patient's intended course of action, access to suicide methods, possible motivations, reasons for living, and quality of the therapeutic alliance. 2
• Screen for aggressive or psychotic ideas, including thoughts of physical/sexual aggression or homicide. 2

Comprehensive Mood Assessment Components

Mental Status Examination

• The mental status examination must include direct observation and documentation of the patient's current mood state and level of anxiety. 2
• Assess hopelessness, as it carries significant clinical implications for risk stratification. 2
• Evaluate thought content and process by examining the logical flow and organization of thoughts through observation during the clinical interview. 2
• Examine speech characteristics, including fluency and articulation, which can reflect underlying thought processes. 2

Contextual and Stressor Assessment

• The assessment should identify signs and symptoms of depression, the severity of associated symptoms (e.g., fatigue), possible stressors, risk factors, and times of vulnerability. 1
• Problem checklists are available to guide the assessment of possible stressors and can be amended to include areas unique to specific patient populations. 1

Alternative and Supplementary Assessment Tools

Self-Report Measures for Depression

When the PHQ-9 is not suitable or additional assessment is needed, alternative validated instruments include: 1

• Beck Depression Inventory-II (BDI-II): 21-item self-report scale assessing behavioral, cognitive, and somatic components of depression including suicidal ideation; scores ≥20 suggest clinical depression. 1
• Center for Epidemiological Studies–Depression Scale (CES-D): 20-item scale (or 10-item short form) assessing negative affect and mood, positive mood or well-being, somatic, and interpersonal domains; scores ≥16 suggest moderate to severe depressive symptomatology; relatively unaffected by physical symptoms. 1
• Geriatric Depression Scale (GDS): 30-item scale (or 15-item short form) specifically designed for elderly populations to assess depressive symptoms more common among older adults. 1

Brief Screening Tools for Distress

• Distress Thermometer (DT): Single-item measure where individuals rate distress levels during the past week on a scale from 0 (none) to 10 (extreme distress); recommended cutoff is 4 for mixed populations and 5 for palliative care. 1
• Emotional Thermometers (ET): Five visual analog scales assessing distress, anxiety, depression, anger, and need for help; individuals rate emotional upset experienced in the past week from 0 (none) to 10 (extreme). 1
• K-10: 10-item global measure of psychosocial distress assessing nervousness, agitation, psychological fatigue, and depression in the last 4 weeks; total score ranges from 10 to 50 with recommended cutoff of 22; outperforms DT alone, and combination of K-10 and DT provides better assessment. 1

Anxiety-Specific Measures

• Beck Anxiety Inventory (BAI): 21-item self-report scale assessing somatic symptoms of autonomic arousal and panic; scores ≥10 suggest mild anxiety and ≥19 suggest moderate anxiety; designed to discriminate anxiety from depressive symptoms. 1
• Generalized Anxiety Disorder Questionnaire-IV (GAD-Q-IV): 9-item scale assessing symptoms of generalized anxiety disorder per DSM-IV, including uncontrollable worry, functional impairment, physical symptoms, and subjective distress. 1

Diagnostic Clarification and Medical Rule-Out

Further Assessment for Positive Screens

• If moderate to severe or severe symptomatology is detected through screening, individuals must have further diagnostic assessment to identify the nature and extent of the depressive symptoms and the presence or absence of a mood disorder. 1
• Medical or substance-induced causes of significant depressive symptoms (e.g., interferon administration) must be determined and treated. 1

Medical Causes to Evaluate

• Neurological causes include stroke, traumatic brain injury, CNS infections, CNS malignancies, seizure disorders, and neurodegenerative diseases. 3
• Metabolic and endocrine disturbances include hypoglycemia, hyponatremia, hypocalcemia, and thyroid disorders. 3
• Substance-induced causes include medication side effects, drug intoxication, and withdrawal states. 3

Distinguishing Organic from Psychiatric Presentation

• Organic flat affect can mimic primary psychiatric depression; post-stroke aprosodic speech appears as flat affect but results from neurological damage, not depression. 3
• Fluctuating presentation suggests delirium rather than primary mood disorder. 3
• Persistent flat affect in the context of neurological findings indicates organic cause. 3

Special Considerations

Bipolar Disorder Screening

• Prior to initiating treatment with an antidepressant, patients with depressive symptoms must be adequately screened to determine if they are at risk for bipolar disorder. 4, 5
• Screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. 4, 5
• A major depressive episode may be the initial presentation of bipolar disorder, and treating such an episode with an antidepressant alone may increase the likelihood of precipitating a mixed/manic episode in at-risk patients. 4, 5

Multi-Informant Assessment

• Incorporating informant-based assessment using structured instruments such as the AD8, IQCODE, and NPI-Q can provide reliable information on changes in cognition, activities of daily living, mood, and neuropsychiatric symptoms. 2
• The Neuropsychiatric Inventory-Questionnaire (NPI-Q) is specifically recommended for assessing behavioral and mood changes, particularly in cognitive disorders. 2

Population-Specific Approaches

• Tailored assessment approaches are required for older adults, as depression is more difficult to detect and often presents atypically. 3
• Modified assessment approaches are necessary for patients with cognitive impairment. 3
• Culturally sensitive assessment tools should be used when possible for culturally diverse patients. 3

Team-Based Assessment and Referral

Shared Responsibility

• Assessments should be a shared responsibility of the clinical team, with designation of those expected to conduct assessments as per scope of practice. 1
• The clinical team must decide when referral to a psychiatrist, psychologist, or equivalently trained professional is necessary. 1

Documentation Requirements

• Document the rationale for treatment selection, estimated suicide risk, and rationale for any clinical tests ordered. 2
• Engage the patient in shared decision-making by discussing treatment-related preferences, explaining the differential diagnosis, and collaborating on treatment decisions. 2

Critical Pitfalls to Avoid

• Relying solely on symptom counts when assessing depression is misleading; phased screening that incorporates risk factors and functional impairment is required. 2
• Omitting assessment of suicidal ideation is harmful and represents a required component of the mental status examination. 2
• Attributing thought disorders solely to mania or attentional disturbances is inaccurate; these are independent dimensions requiring separate assessment. 2
• Interpreting cognitive screening results without considering education level, language barriers, and cultural factors can be misleading. 2
• Conducting evaluations without obtaining collateral information when cognitive impairment or behavioral changes are suspected results in incomplete assessment. 2
• Changes in questionnaire scores may not fully capture patients' experience of changes in their mood; clinicians should be cautious in interpreting changes in questionnaire scores without further clinical assessment. 6