What diagnostic assessments are needed for a patient with a history of bullying, abusive relationship, and marijuana use, presenting with depressive, manic, and anxiety symptoms?

Diagnostic Assessment for Mixed Mood Symptoms with Substance Use History

Immediate Safety and Medical Stability Assessment

For any patient presenting with mixed depressive, manic, and anxiety symptoms, the first priority is ruling out medical causes and assessing immediate safety risks, particularly given the history of trauma and substance use. 1

Critical Safety Evaluation (Perform Immediately)

• Assess for suicidal ideation, intent, and plan - patients with mixed mood states (depressive and manic symptoms occurring together) carry significantly increased suicide risk 2, 3
• Evaluate for risk of harm to self or others - requires immediate psychiatric referral if present 1
• Screen for psychotic symptoms - acute psychosis may be the first presentation of mania in this age group 2

Medical Clearance Requirements

Routine laboratory testing is NOT indicated if the patient is alert, cooperative, with normal vital signs and a noncontributory physical examination. 1 However, given this patient's presentation, targeted testing is warranted:

Required Medical Workup

• Vital signs assessment - tachycardia, tachypnea, hypertension may indicate substance intoxication, withdrawal, or medical causes of psychiatric symptoms 1
• Focused physical examination looking specifically for:
  • Signs of substance intoxication or withdrawal (tremor, sweating, pupil changes) 1
  • Neurological abnormalities (focal deficits suggesting CNS pathology) 1
  • Signs of medical illness that can present with psychiatric symptoms 1

Laboratory Testing (Only if Clinically Indicated)

Obtain targeted labs ONLY if history or physical examination suggests medical etiology: 1

• Urine drug screen - While routine screening does not affect disposition in stable patients 1, it may be useful here given active marijuana use and need to establish baseline substance use patterns 4, 5
• Thyroid function (TSH) - only if signs/symptoms of thyroid dysfunction present 1
• Electrolytes - only if concerned for eating disorder, purging behaviors, or dehydration 1
• Complete blood count, liver function tests - only if physical findings suggest medical illness 1

Neuroimaging (CT/MRI) is NOT routinely indicated unless focal neurological findings, altered mental status, or new-onset psychosis with concerning features are present 1

Psychiatric Diagnostic Assessment

Structured Symptom Screening

Use validated screening instruments to quantify symptom severity: 1

• PHQ-9 for depression - scores ≥15 indicate moderate-to-severe depression requiring further diagnostic assessment 1
• GAD-7 for anxiety - establish baseline anxiety severity 1
• Mood Disorder Questionnaire or similar bipolar screening tool - essential given manic symptoms 2

Comprehensive Psychiatric History

Obtain detailed information about: 2, 3

Mood Episode Characteristics

• Duration and pattern of mood symptoms - manic episodes require ≥1 week of symptoms (or any duration if hospitalization needed) 2
• Specific manic symptoms present: inflated self-esteem/grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility, increased goal-directed activity, excessive involvement in high-risk activities 2
• Depressive symptoms: anhedonia, depressed mood, sleep changes, energy changes, concentration difficulties 1
• Temporal relationship between mood states - do symptoms occur simultaneously (mixed episode) or cycle? 2

Substance Use Pattern

• Cannabis use details: frequency, amount, timing relative to mood symptoms 4, 5, 6
  • Cannabis use is associated with earlier age of first manic episode and increased manic/depressive symptom severity 5, 6
  • Cannabis use often precedes first manic episodes, though causality remains unclear 6
  • Lifetime prevalence of cannabis use in bipolar disorder is 52-71% 5
• Other substance use history - alcohol use is associated with depressive episodes in bipolar disorder 4

Trauma and Psychosocial History

• History of bullying and abusive relationships - assess for PTSD symptoms, which can mimic mood instability 2, 3
• Current stressors: family conflict, relationship problems, academic/occupational difficulties 1
• Interpersonal relationship patterns - fear of abandonment, unstable relationships suggest borderline personality disorder 3

Family Psychiatric History

• Family history of bipolar disorder, depression, or other mood disorders significantly increases diagnostic likelihood of bipolar disorder 2
• Family history of substance use disorders 5

Differential Diagnosis Considerations

Critical distinctions to make: 2, 3

• Bipolar disorder vs. borderline personality disorder - both present with mood instability, but BPD shows rapid mood shifts (hours), unstable relationships, identity disturbance, and fear of abandonment 3
• Primary mood disorder vs. substance-induced mood disorder - cannabis use is associated with manic and depressive symptoms, but temporal relationship is key 4, 5, 7
• Mania vs. ADHD - can appear similar but represent distinct conditions 2
• Mania vs. behavioral activation from antidepressants (if previously treated) - activation occurs early (first month) and improves with dose reduction; mania appears later and persists despite medication changes 2
• Mood disorder vs. PTSD - trauma history requires assessment for PTSD symptoms that may mimic mood instability 2

Assessment of Functional Impairment

Document specific impairments in: 1

• Daily functioning and self-care
• Academic or occupational performance
• Social relationships and family functioning
• Sleep patterns and quality
• Quality of life measures

Diagnostic Formulation

Based on assessment findings, determine: 1, 2

1. Primary psychiatric diagnosis (bipolar disorder type I or II, major depressive disorder, anxiety disorder, borderline personality disorder, or combination)
2. Comorbid diagnoses including substance use disorder severity (abuse vs. dependence) 5
3. Trauma-related diagnoses (PTSD, adjustment disorder)
4. Severity level requiring outpatient vs. intensive outpatient vs. inpatient treatment 1

Referral Criteria

Immediate psychiatric referral required for: 1

• Suicidal ideation with plan or intent
• Homicidal ideation
• Psychotic symptoms
• Severe agitation or inability to cooperate with assessment
• PHQ-9 score ≥20 (severe depression) 1
• Mixed manic-depressive features with high suicide risk 2, 3

Routine psychiatric referral (within days) for: 1

• PHQ-9 score 15-19 (moderate-to-severe depression)
• Confirmed manic or hypomanic symptoms
• Moderate-to-severe anxiety interfering with function
• Comorbid substance use disorder requiring specialized treatment 5

Common Pitfalls to Avoid

• Do not obtain routine laboratory testing or neuroimaging in stable patients - this is low yield and costly 1
• Do not dismiss cannabis use as benign - it is strongly associated with worse outcomes in bipolar disorder, including increased symptom severity and earlier age of onset 5, 6
• Do not confuse irritable mania with common anger problems - particularly given high comorbidity with trauma history 2
• Do not apply adult diagnostic criteria without considering developmental context if patient is adolescent/young adult 2
• Do not miss borderline personality disorder in patients with trauma history and rapid mood shifts - this requires different treatment approach (DBT) 3
• Do not assume substance use is self-medication - evidence suggests cannabis use precedes and exacerbates mood episodes rather than treating them 4, 7